ATI RN Pharmacology for Nursing (8th edition) Eye and Ear Disorders PDF

CHAPTER 14 UNIT 2 MEDICATIONS AFFECTING THE NERVOUS SYSTEM Beta-adrenergic blockers CHAPTER 14 Eye and Ear NONSELECTIVE BETA BLOCKERS (which have both beta1...

CHAPTER 14 UNIT 2 MEDICATIONS AFFECTING THE NERVOUS SYSTEM Beta-adrenergic blockers CHAPTER 14 Eye and Ear NONSELECTIVE BETA BLOCKERS (which have both beta1 Disorders and beta2 properties) Timolol Carteolol Eye disorders Metipranolol Levobunolol CARDIOSELECTIVE BETA1 BLOCKERS: Betaxolol Glaucoma is a frequent cause of blindness. Damage to the optic nerve occurs when PURPOSE aqueous humor does not exit from the anterior chamber of the eye. This results in the buildup EXPECTED PHARMACOLOGICAL ACTION Beta blockers decrease IOP by decreasing the amount of of aqueous humor, increased intraocular aqueous humor produced. pressure (IOP), and loss of vision. THERAPEUTIC USES TYPES OF GLAUCOMA Topical beta blockers are used primarily to treat POAG. They can be prescribed in combination with other Primary open-angle glaucoma (POAG) topical medications to lower IOP. POAG is the most common form of glaucoma. These medications are occasionally used to treat acute Peripheral vision is lost gradually, with central visual closed-angle glaucoma on an emergency basis. field loss occurring if damage to the optic nerve continues. Clients typically do not experience manifestations until there is widespread damage. Manifestations can include COMPLICATIONS halos seen around lights, loss of peripheral vision, and headaches. Stinging discomfort The expected reference range for IOP is 10 to 21 mm Reports of temporary stinging discomfort in the eye Hg. IOP greater than 21 mm Hg is a major risk factor for immediately after drop is instilled POAG. However, it can occur at therapeutic IOP levels. Treatment includes medication therapy to reduce IOP. CLIENT EDUCATION: This effect is transient. Surgical intervention is indicated if IOP cannot be reduced by medications. Occasional conjunctivitis, blurred vision, POAG is treated with the following medications: photophobia, dry eyes ◯ Beta adrenergic blockers ◯ Alpha CLIENT EDUCATION: Report these effects to the provider. 2 adrenergic agonists ◯ Prostaglandin analogs Systemic effects of beta blockade on heart and lungs ◯ Cholinergic agonists ◯ Carbonic anhydrase inhibitors Heart block, bradycardia, bronchospasms, and hypotension Angle-closure (narrow-angle) glaucoma CLIENT EDUCATION This is an acute disorder with a sudden onset, resulting Avoid excessive dosing to prevent systemic effects. in irreversible blindness within 1 to 2 days without When taking beta1 blockers, monitor for bradycardia. emergency treatment. Notify the provider for heart rate less than 58/min. Findings include acute onset of ocular pain, seeing halos around lights, brow pain, nausea, blurred vision, and photophobia. The optic nerve is damaged when the CONTRAINDICATIONS/PRECAUTIONS aqueous humor builds up as a result of displacement Pregnancy Risk Category C of the iris. Do not use beta2 blockers for clients who have chronic Treatment includes medication therapy to reduce IOP, with respiratory disease because they can constrict airway subsequent corrective surgery for restoration of the iris. and cause bronchospasms. Use beta1 blockers with Although several other classes of glaucoma medications caution in clients who have chronic respiratory disease. are used to treat angle-closure glaucoma, osmotic Do not use beta blockers for clients who have sinus agents are first-line medications used to control the bradycardia, or AV heart block, and use with caution in condition until corrective surgery can be implemented. clients who have heart failure. RN PHARMACOLOGY FOR NURSING CHAPTER 14 EYE AND EAR DISORDERS 109  INTERACTIONS Reddened sclera Oral beta blockers and calcium channel blockers can Caused by blood-vessel engorgement increase cardiovascular and respiratory effects. CLIENT EDUCATION: Be aware of the possibility of this effect. CLIENT EDUCATION: Inform the provider if taking any of these medications. Hypotension, drowsiness Beta blockers can interfere with some effects of insulin. Brimonidine crosses the blood-brain barrier CLIENT EDUCATION: If diabetic, monitor blood glucose. CLIENT EDUCATION: Use caution with driving and other tasks, and inform the provider if dizziness and/or weakness occur. NURSING ADMINISTRATION Instill one drop in the affected eye once or twice daily. CONTRAINDICATIONS/PRECAUTIONS Review the proper method of instilling eye drops, and provide instruction to a family member if indicated. Advise clients who wear soft contact lenses to Avoid touching any part of the applicator, and keep the administer brimonidine with lenses removed. Delay lid in place when not in use. insertion of the lens at least 15 min after administration Hold gentle pressure on the nasolacrimal duct for to prevent absorption of medication into the lens. 30 to 60 seconds immediately after instilling the drop(s) Brimonidine is Pregnancy Risk Category B, while to prevent or minimize any expected systemic effect. apraclonidine, brimonidine, and timolol combination Monitor pulse rate/rhythm as indicated for medication are Pregnancy Risk Category C. beta blocker. INTERACTIONS Alpha2 adrenergic agonists Antihypertensive medications can intensify hypotension caused by brimonidine. SELECT PROTOTYPE MEDICATION: Brimonidine CLIENT EDUCATION: Inform the provider if taking any OTHER MEDICATION: Apraclonidine antihypertensive medications. ALPHA 2 AGONIST/BETA BLOCKER COMBINATION: MAOIs can decrease effects of brimonidine and cause Brimonidine and timolol hypertensive crisis. CLIENT EDUCATION: Inform the provider if taking MAOIs. PURPOSE NURSING ADMINISTRATION EXPECTED PHARMACOLOGICAL ACTION Review proper method of administering eye drops and minimizing systemic effects. Brimonidine decreases production and outflow of aqueous Monitor blood pressure for hypotension or hypertension. humor to lower IOP. THERAPEUTIC USES Prostaglandin analogs Brimonidine is used as a first-line medication for SELECT PROTOTYPE MEDICATION: Latanoprost long-term topical treatment of POAG. Apraclonidine is a short-term therapy for POAG only and OTHER MEDICATIONS is also used preoperatively for laser eye surgeries. Travoprost Bimatoprost COMPLICATIONS PURPOSE Stinging discomfort, pruritus Localized stinging discomfort and pruritus of conjunctiva EXPECTED PHARMACOLOGICAL ACTION Sensation that a foreign body is in the eye Latanoprost reduces IOP by increasing aqueous humor CLIENT EDUCATION: Do not rub the eyes. outflow through relaxation of ciliary muscle. Dilated pupils, blurred vision, headache, dry mouth THERAPEUTIC USES CLIENT EDUCATION: Report these effects. These agents are topical first-line medications for clients who have POAG and ocular hypertension. (14.1) 110 CHAPTER 14 EYE AND EAR DISORDERS CONTENT MASTERY SERIES  COMPLICATIONS Carbonic anhydrase Bulging of ocular blood vessels inhibitor (systemic) CLIENT EDUCATION: Inform clients about the possibility SELECT PROTOTYPE MEDICATION: Acetazolamide of this effect. OTHER MEDICATIONS: Methazolamide Increased pigmentation Permanent increased brown pigmentation of the iris, PURPOSE usually occurring in individuals with a brown tint to the iris (can also cause pigmentation of lids, lashes) EXPECTED PHARMACOLOGICAL ACTION CLIENT EDUCATION: This change is permanent but does Reduces production of aqueous humor by causing diuresis not progress further after medication is discontinued. through renal effects. Stinging, burning, reddened conjunctiva CLIENT EDUCATION: Do not rub the eyes. THERAPEUTIC USES Quickly lower IOP in clients for whom other medications Blurred vision have been ineffective. Acetazolamide, a nonantimicrobial sulfonamide, can CLIENT EDUCATION: Report to the provider. be used as an emergency medication prior to surgery for acute angle-closure glaucoma and as a second-line Migraine medication for treatment of POAG. Rare adverse effect Acetazolamide can also be used to treat acute altitude sickness, seizures, and heart failure (as a diuretic). CLIENT EDUCATION: Report to the provider. CONTRAINDICATIONS/PRECAUTIONS COMPLICATIONS Medications in this class are Pregnancy Risk Category C. Severe allergic reactions Severe allergic reactions (anaphylaxis) Osmotic agents Possible cross-sensitivity with sulfonamides NURSING ACTIONS: Ask about sulfonamide allergy. SELECT PROTOTYPE MEDICATION: Mannitol CLIENT EDUCATION: Monitor for effects and notify provider. Serious blood disorders PURPOSE Rare serious blood disorders (bone marrow depression) EXPECTED PHARMACOLOGICAL ACTION CLIENT EDUCATION: Recognize and immediately report effects. Osmotic agents decrease intraocular pressure by making the plasma hypertonic, thus drawing fluid from the Gastrointestinal effects anterior chamber of the eye. Gastrointestinal (GI) effects (nausea, diarrhea) THERAPEUTIC USES NURSING ACTIONS: Report GI adverse effects and weight loss to provider. These agents treat the rapid progression of closed-angle glaucoma to prevent blindness. Electrolyte depletion (sodium and potassium), dehydration, altered liver function COMPLICATIONS NURSING ACTIONS: Prepare clients for the need to obtain regular laboratory testing. Weigh daily, monitor for Adverse effects include headache, nausea, vomiting, postural hypotension, increase fluid intake to 2 to 3 L/day, edema, and fluid and electrolyte imbalance. unless contraindicated. Generalized flu-like manifestations CONTRAINDICATIONS/PRECAUTIONS Headache, fever, body aches malaise Medications in this class are Pregnancy Risk Category C. CLIENT EDUCATION: Monitor for possible reactions. RN PHARMACOLOGY FOR NURSING CHAPTER 14 EYE AND EAR DISORDERS 111  Central nervous system disturbances NURSING ADMINISTRATION Paresthesias of extremities, fatigue, sleepiness, Acetazolamide is available orally as a tablet or a capsule. It rarely seizures is also available for parenteral administration. NURSING ACTIONS Educate client about possible reactions. NURSING EVALUATION OF Medication can be discontinued. MEDICATION EFFECTIVENESS Glucose disturbances Depending on therapeutic intent, effectiveness can be evidenced by the following. In clients who have diabetes mellitus Reduced IOP CLIENT EDUCATION: If diabetic, closely monitor blood Safe self-administration of medication glucose and watch for indications of hypo- or hyperglycemia. Prevention or minimization of systemic effects Nephrolithiasis CLIENT EDUCATION: Report manifestations of stones to the provider (flank pain). 14.1 Second-line topical medications for glaucoma CONTRAINDICATIONS/PRECAUTIONS Direct-acting cholinergic Pregnancy Risk Category C (teratogenic) (muscarinic) agonist Use during lactation only after evaluation by the provider. PROTOTYPE: Pilocarpine PURPOSE Second-line treatment for POAG; lowers IOP INTERACTIONS indirectly through ciliary contraction. Also used to treat closed-angle glaucoma. Serious effects (metabolic acidosis) can occur in clients PRECAUTIONS using high-dose aspirin. Pregnancy Risk Category C NURSING ACTIONS: Question clients about aspirin use, ADVERSE EFFECTS and notify the provider. Retinal detachment Acetazolamide can increase the risk of toxic effects Parasympathetic effects (bradycardia, increase in saliva, sweating, flushing, pupil constriction) of quinidine. Decreased visual acuity CLIENT EDUCATION: Notify the provider of concurrent use Miosis and watch for indications of toxicity (decreased heart rate). Blurred vision Acetazolamide can decrease blood levels of lithium. Carbonic anhydrase inhibitor CLIENT EDUCATION: If taking lithium, watch for increased indications of mania. Monitor lithium levels regularly. PROTOTYPE: Dorzolamide Also available in combination with timolol Acetazolamide can increase osteomalacia, an adverse PURPOSE effect of phenytoin. Second-line treatment for POAG, which CLIENT EDUCATION: If taking phenytoin, watch for bone decreases aqueous humor production. pain or weakness and report manifestations to the provider. Timolol/dorzolamide combination produces increased effect of both medications. Sodium bicarbonate increases the risk of kidney stones. PRECAUTIONS NURSING ACTIONS: Question clients about the use of Pregnancy Risk Category C sodium bicarbonate and other over-the-counter antacids. ADVERSE EFFECTS Localized allergic reactions in up to 15% Blurred vision, dryness, photophobia Can absorb into soft contacts Ocular stinging, conjunctivitis, and lid reaction Bitter taste 112 CHAPTER 14 EYE AND EAR DISORDERS CONTENT MASTERY SERIES  Ear disorders Antibiotics used to treat acute otitis media in clients who have a type 1 penicillin allergy (severe) Ceftriaxone IM, IV (severe illness) Azithromycin PO, IV Acute otitis media Clindamycin PO, IM, IV (macrolide antibiotic) This condition occurs most often in young children. A bacterial or a viral infection causes a buildup of fluid in the middle ear (middle ear effusion). PURPOSE The major indication is acute onset of pain. Objective findings include erythema, bulging of the tympanic membrane, and fever. Diagnosis is confirmed when EXPECTED PHARMACOLOGICAL ACTION there is acute onset of manifestations, middle-ear Eradication of infection effusion, and middle-ear inflammation. Treatment for bacterial infection, especially in infants THERAPEUTIC USES and young children, is an antibiotic. Treatment for viral infection involves managing manifestations (promote Used to treat otitis media and various other bacterial comfort, reduce fever). infections throughout the body. Because of the increase in antibiotic-resistant bacteria, the current trend is to administer medications for pain relief (acetaminophen, COMPLICATIONS ibuprofen), observe children over age 2 for 48 to Possible allergic reaction 72 hr, and prescribe antibiotics if the condition does not resolve or worsens over several days. Most common risk when taking penicillin Medications for treating otitis media NURSING ACTIONS ◯ Oral penicillins Question the client and family regarding the presence of ◯ Other antimicrobials, oral or parenteral penicillin or other antibiotic allergy. ◯ Pain medication The client might need alternative medication. Incidence of acute otitis media in infants and children A skin test can be used to test for sensitivity. can be reduced by yearly influenza immunization and immunization with pneumococcal conjugate vaccine. GI upset Usually less with amoxicillin than with ampicillin Otitis externa NURSING ACTIONS: Educate family to inform the provider This condition, also known as swimmer’s ear, is caused of severe diarrhea, especially in an infant or young child. by a bacterial infection of the external auditory canal. Any object that abrades or leaves moisture in the canal Suprainfection facilitates colonization of bacteria and the onset of otitis externa. With other microbes (oral candidiasis) Manifestations include acute onset of pain, especially NURSING ACTIONS: Report indications of new infection to with movement of the pinna, itching, diminished the provider. hearing, and purulent discharge. Treatment usually resolves infection within 10 days. Otitis externa is usually treated by topical antimicrobial/ CONTRAINDICATIONS/PRECAUTIONS anti-inflammatory combination. Amoxicillin and amoxicillin/clavulanate are Pregnancy Risk Category B. Antimicrobials Amoxicillin is contraindicated for clients who have an allergy to penicillin. SELECT PROTOTYPE MEDICATION: Amoxicillin Use amoxicillin with caution in clients who have an allergy to cephalosporins due to possibility of cross-sensitivity. OTHER MEDICATION: Amoxicillin/clavulanate PO Use cautiously in infants younger than 3 months of age due Antibiotics used to treat acute otitis media in clients to immature renal system and increased risk for toxicity. who have a type 11 penicillin allergy (mild) or penicillin-resistant otitis media Ceftriaxone IM, IV (severe illness) Cefdinir PO Cefuroxime PO, IM, IV Cefpodoxime PO RN PHARMACOLOGY FOR NURSING CHAPTER 14 EYE AND EAR DISORDERS 113  NURSING ADMINISTRATION CONTRAINDICATIONS/PRECAUTIONS Amoxicillin is usually prescribed 3 times daily PO. Each of these fluoroquinolone antibiotic plus steroid medications are Pregnancy Risk Category C. CLIENT EDUCATION Take amoxicillin with food to minimize GI upset. Take the full course of antibiotics as prescribed. NURSING ADMINISTRATION If taking hormonal contraception to prevent pregnancy, use a backup birth control method (condom) while Review the method for instilling otic drops. taking antibiotics. Warm the medication by gently rolling the container between hands before instilling drops. Cold drops can cause dizziness. Gently shake medication that is in NURSING EVALUATION OF suspension form. MEDICATION EFFECTIVENESS Place the client on the unaffected side. Keep clients in a side-lying position for 5 min with the Depending on therapeutic intent, effectiveness can be affected ear up after instilling drops. Place a small piece evidenced by of cotton in the ear. Avoid packing it tightly. Remove Reduction of manifestations (fever, earache) cotton after 15 min. Absence of infection Absence of recurrence of infection CLIENT EDUCATION Take the full course of medication. Movement of the tragus or pinna can be very painful Fluoroquinolone antibiotic when instilling otic drops. plus steroid medication Prevent otic medications from being placed in the eye or ingested orally. Prevent otitis externa by SELECT PROTOTYPE MEDICATION: Ciprofloxacin plus ◯ Keeping foreign bodies (cotton swabs, out of the ear hydrocortisone otic drops canal, and avoiding the use of manual measures to OTHER MEDICATIONS remove cerumen). Acetic acid 2% solution otic drops ◯ Drying the ear canal after bathing or swimming, Ciprofloxacin plus dexamethasone otic drops using a towel, and tilting the head to Ofloxacin otic drops promote drainage. ◯ Avoiding the use of earplugs, except for swimming or if needed in a loud environment to prevent PURPOSE hearing loss. EXPECTED PHARMACOLOGICAL ACTION NURSING EVALUATION OF The bactericidal effect of ciprofloxacin and MEDICATION EFFECTIVENESS anti-inflammatory effect of hydrocortisone should Depending on therapeutic intent, effectiveness can be decrease pain, edema, and erythema in the ear canal. evidenced by the following. Subsiding of manifestations THERAPEUTIC USES Use of measures to prevent reinfection Topical medications to treat otitis externa COMPLICATIONS CNS effects Dizziness, lightheadedness, tremors, restlessness, convulsions CLIENT EDUCATION: Inform the provider if any of these occur. Rash NURSING ACTIONS: Question the client/family about allergies to fluoroquinolone antibiotics or to steroids (dexamethasone or cortisone). 114 CHAPTER 14 EYE AND EAR DISORDERS CONTENT MASTERY SERIES  Application Exercises Active Learning Scenario 1. A nurse is instructing a client who has a new A nurse in a provider’s office is teaching a client who has prescription for timolol how to insert eye drops. a prescription for ciprofloxacin/hydrocortisone about the The nurse should instruct the client to press medication and how to prevent otitis externa. Use the ATI on which of the following areas to prevent Active Learning Template: Medication to complete this item. systemic absorption of the medication? THERAPEUTIC USES: Identify two A. Bony orbit therapeutic effects of the medication. B. Nasolacrimal duct COMPLICATIONS: Identify two potential adverse effects. C. Conjunctival sac CLIENT EDUCATION: Identify two D. Outer canthus actions to prevent otitis externa. 2. A nurse is teaching a client who has a new prescription for brimonidine ophthalmic drops and wears soft contact lenses. Which of the following instructions should the nurse include in the teaching? A. “This medication can stain your contacts.” B. ”This medication can cause your pupils to constrict.” C. “This medication can absorb into your contacts.” D. “This medication can slow your heart rate.” 3. A nurse in an emergency department is reviewing the medical record of a client who is being evaluated for angle-closure glaucoma. Which of the following findings are indicative of this condition? A. Insidious onset of painless loss of vision B. Gradual reduction in peripheral vision C. Severe pain around eyes D. Intraocular pressure 12 mm Hg 4. A nurse is teaching a client about preventing otitis externa. Which of the following instructions should the nurse include? A. Clean the ear with a cotton-tipped swab daily. B. Place earplugs in the ears when sleeping at night. C. Use a cool water irrigation solution to remove earwax. D. Tip the head to the side to remove water from the ears after showering. 5. A nurse in a provider’s office is instructing a guardian of a toddler how to administer ear drops. Which of the following instructions should the nurse include? (Select all that apply.) A. “Place the child on the unaffected side when you are ready to administer the medication.” B. “Warm the medication by gently rolling it between your hands for a few minutes.” C. “Gently shake medication that is in suspension form.” D. “Keep the child on their side for 5 minutes after instillation of the ear drops.” E. “Tightly pack the ear with cotton after instillation of the ear drops.” RN PHARMACOLOGY FOR NURSING CHAPTER 14 EYE AND EAR DISORDERS 115  Application Exercises Key Active Learning Scenario Key 1. A. Pressing on the bony orbit will not prevent Using the ATI Active Learning Template: Medication systemic absorption of the medication. THERAPEUTIC USES: The bactericidal effects of ciprofloxacin B. CORRECT: Pressing on the nasolacrimal duct and the anti-inflammatory effect of hydrocortisone blocks the lacrimal punctum and prevents decreases pain, edema, and erythema in the ear. systemic absorption of the medication. C. Pressing on the conjunctival sac will not prevent COMPLICATIONS systemic absorption of the medication. Rash D. Pressing on the outer canthus will not prevent Dizziness, lightheadedness, tremors, restlessness, and convulsions systemic absorption of the medication. CLIENT EDUCATION NCLEX® Connection: Pharmacological and Parenteral Therapies, Keep foreign bodies out of ear canal. Medication Administration Avoid manual measures to remove cerumen. Dry ear canal after bathing or swimming using a towel. 2. A. Rifampin can stain soft contact lenses. Avoid use of ear plugs except for swimming. Brimonidine does not stain contacts. NCLEX® Connection: Pharmacological and Parenteral Therapies, B. Brimonidine can cause mydriasis or dilated pupils. Medication Administration C. CORRECT: Brimonidine can absorb into soft contact lenses. The client should remove their contacts then instill the medication and wait at least 15 min before putting the contacts back in. D. Beta adrenergic blockers (timolol) can slow the heart rate. Brimonidine can cause hypertension or hypotension. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration 3. A. Acute-angle glaucoma is painful and has a sudden onset. B. Gradual loss of peripheral vision is a manifestation of primary open-angle glaucoma. C. CORRECT: Severe pain around eyes that radiates over the face is a manifestation of acute angle-closure glaucoma. D. An IOP of 12 mm Hg is within the expected reference range. Elevated IOP is a manifestation of angle-closure glaucoma. NCLEX® Connection: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions 4. A. The client should not insert anything in the ear because this can push cerumen into the eardrum, damage the epithelium, or puncture the eardrum. B. The client should wear earplugs only when swimming to reduce the risk for otitis externa. C. The client should not use cool water irrigation solution to remove cerumen. Cool fluid can cause vertigo, dizziness, and nausea. The client should not remove cerumen from the ear to reduce the risk for otitis externa. D. CORRECT: The client should remove water from the ear after showering or swimming to reduce the risk for otitis externa. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration 5. A. CORRECT: The guardian should have the child on the unaffected side to allow access to the affected ear and to promote drainage of the medication by gravity into the ear. B. CORRECT: The guardian should warm the medication by rolling it between their hands. Administering the medication cold can cause dizziness. C. CORRECT: The guardian should gently shake medication that is in suspension form to evenly- disperse the medication. D. CORRECT: The guardian should keep the child on their side to promote drainage of the medication by gravity into the ear. E. The guardian should loosely pack the child’s ear with cotton. NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration 116 CHAPTER 14 EYE AND EAR DISORDERS CONTENT MASTERY SERIES