Study Guide for Module 4: EENT PDF

Study Guide for Module 4: EENT Eyes © Based on clinical presentation, distinguish between blepharitis and conjunctivitis. Blepharitis: A typical chief complaint for blepharitis includes, "My eyelids are red, swollen, and itchy. I have crusting on my eyelashes when I wake up...

Study Guide for Module 4: EENT Eyes © Based on clinical presentation, distinguish between blepharitis and conjunctivitis. Blepharitis: A typical chief complaint for blepharitis includes, "My eyelids are red, swollen, and itchy. I have crusting on my eyelashes when I wake up." Subjective Data: Red, swollen, or tender eyelids Crusting or scaling along the eyelid margins, particularly noticeable upon waking Flaky skin at the lash line Itchy, dry, or burning eyes A gritty or foreign body sensation in the eyes Complaints of frequent eye irritation or redness Conjunctivitis: A typical chief complaint consistent with bacterial conjunctivitis might be, “My eyes are irritated and red with thick discharge. Subjective data: Purulent or mucopurulent discharge (hallmark symptom) Eye redness and irritation Eyelid matting, particularly upon waking Unilateral onset that may spread to the other eye Mild to moderate discomfort © List pharmacological and non-pharmacological management of a patient with blepharitis. Non-Pharm: Eyelid hygiene with warm compresses for 5-10 minutes 2–4 times daily Gentle lid scrubs with diluted baby shampoo or specialized lid scrubs Regular cleaning of the eyelid margins to remove crusts and debris Education about hygiene practices and adherence to the prescribed regimen is a critical component of care Pharm: Topical antibiotic ointments such as Ilotycin (erythromycin) or Bacitracin, Baciguent (bacitracin) to treat bacterial colonization, especially in cases of infection or if the condition is chronic. If there is significant inflammation, corticosteroid eye drops or ointments may be considered for short-term relief © Discuss patient teaching to be included for a patient with a hordeolum. Apply warm compresses for 5-10 minutes 3–4 times daily to promote drainage and relieve discomfort Eyelid hygiene with gentle cleansing of the affected eyelid to remove crusting and debris Avoid squeezing the lesion, as this may worsen the infection or lead to complications Educating the patient on managing the condition at home and avoiding squeezing the stye helps improve compliance and prevent future occurrences © Discuss the evidence-based treatment for treating hordeola with steroids/antibiotics. Topical antibiotics such as erythromycin ophthalmic ointment or bacitracin ophthalmic ointment for external infections Oral antibiotics may be prescribed for more severe or recurrent cases, especially if cellulitis is suspected or the patient has a history of recurrent styes **The book states that antibiotics and steroids are not indicated??** © Name 3 types of conjunctivitis. Allergic, bacterial, and viral © What is the most common causative organism in bacterial conjunctivitis? Staphylococcus aureus is the most common cause in adults © Discuss common risk factors of conjunctivitis. © Discuss various scenarios when an APRN should consider referral for a patient diagnosed with conjunctivitis. Vision changes  Severe pain or photophobia Lack of improvement after 7–10 days of appropriate treatment © What if any diagnostics are included in the management of a patient with suspected conjunctivitis? Gram-stained smears and cultures are necessary in the immunocompromised (including neonates) and in severe or unresponsive cases Ears © Discuss the management of a patient diagnosed with mild to moderately infected piercings. Non-Pharm: Regular cleaning with saline solution or antiseptic Warm compresses to reduce swelling & promote drainage Avoid irritants (e.g., alcohol-based products) Remove the earrings Once the infection has resolved, switch to hypoallergenic jewelry (surgical steel, titanium, or gold) Pharm: Mild: Topical mupirocin or bacitracin ointment applied 2–3 times daily Moderate: PO Keflex (cephalexin) based on the suspected pathogen Staphylococcus aureus © What are common risk factors for otitis externa? Immunocompromised and those with frequent water exposure (swimmer’s ear) © List objective data for the patient with suspected otitis externa. Inspection of the Ear Canal Erythema of the ear canal lining, more pronounced in bacterial infections Swelling of the ear canal, which may narrow the canal Presence of discharge Purulent and yellow green in bacterial infections White and flaky in fungal infections Crusting or debris in the ear canal, mainly if the infection is chronic or fungal Fungal spores may appear as white, black, or gray spots Tragus & Pinna Palpation Pain or tenderness upon palpation of the tragus or movement of the pinna (helix), typically more severe in bacterial infections Palpation of the Preauricular Lymph Nodes Mild lymphadenopathy may be present, particularly in bacterial infections, but is not usually as pronounced as in otitis media or systemic infections Audiologic testing: Mild conductive hearing loss may be noted due to obstruction of the ear canal from swelling or discharge © Discuss patient teaching for the patient diagnosed with otitis externa. Avoid water exposure until the infection resolves (e.g., no swimming or submerging the ear in water) Avoid insertion of cotton swabs or foreign objects into the ear canal Keep the ear dry, especially after bathing or showering Gently clean the ear canal with a dry cloth or ear wick, but avoid deep cleaning or scraping of the ear canal Apply a warm compress to relieve pain or discomfort © Discuss complications of otitis externa. Malignant otitis externa is an invasive osteomyelitis of the ear that occurs when the bacterial infection extends into cartilage and bone. most commonly seen in patients who are older, who have diabetes, or who are immunocompromised Associated with severe pain, necrotic ulcerations, and fever Facial paralysis and other cranial nerve abnormalities may also occur © What are the 2 most common causative organisms for otitis media? Streptococcus pneumoniae and Haemophilus influenzae © List the subjective data in a patient with otitis media. A typical chief complaint might be, “I have a fever with throbbing ear pain.” Subjective Data: Ear pain, often throbbing and worse when lying down Fever and irritability, particularly in children Muffled hearing or a sensation of fullness in the ear Fluid drainage if the tympanic membrane ruptures Recent upper respiratory infection symptoms (e.g., cough, nasal congestion) © Describe the ear exam of a patient with otitis media. This is objective data. Mouth, eyes, & nose: Mucosal erythema or nasal congestion indicating concurrent upper respiratory infection Dry mucous membranes suggesting dehydration in febrile cases Absence of lesions or abnormalities in the oral cavity Sinus palpation: Tenderness over frontal & maxillary sinuses suggesting concurrent sinus involvement Lymph node examination: Preauricular or cervical lymphadenopathy indicating a localized immune response Otoscopic examination: Tympanic membrane findings consistent with AOM: Redness or erythema Bulging or distortion of the tympanic membrane Presence of pus or fluid behind the tympanic membrane Decreased mobility upon pneumatic otoscopy Possible perforation with drainage if infection is severe Hearing assessment: Conductive hearing loss due to middle ear effusion © Discuss the pharmacological management for a patient with otitis media. First-line option for bacterial otitis media: PO Amoxil (amoxicillin), 80–90 mg/kg/day in divided doses for 7–10 days (first-line treatment) If inadequate response to amoxicillin (e.g., persistent symptoms or treatment failure): PO Augmentin (amoxicillin/clavulanate) 90 mg/kg/day in divided doses If penicillin allergy Non-severe reaction (e.g., rash, no anaphylaxis) PO Omnicef (cefdinir) 14 mg/kg/day in 1–2 doses Low cross-reactivity with penicillin in patients with a mild allergy (e.g., rash) Other options: Cefuroxime or Cefpodoxime Severe reaction (e.g., anaphylaxis) PO Zithromax (azithromycin) 10 mg/kg on day 1, followed by 5 mg/kg on days 2–5 PO Clarithromycin or Clindamycin (less effective against H. influenzae) Pain management for otitis media Tylenol (acetaminophen) or Advil, Motrin (ibuprofen) for pain relief Topical ear drops (e.g., acetic acid) for pain relief - only if the tympanic membrane is intact Alternative treatments for viral causes Supportive care with hydration, rest, and symptom management (e.g., acetaminophen for pain) No antibiotics indicated for viral infections © What are the complications of otitis media? The most common short-term consequence is decreased conductive hearing loss Eardrum perforation is a common sequela of both AOM and OME Hearing loss, perforation of the eardrum, cholesteatoma, acute mastoiditis, meningitis, and epidermal abscess are less common complications of OM, especially in developed countries  © Discuss various scenarios that would prompt an APRN to consider transfer of care in the patient with otitis media. Severe pain or symptoms that worsen after 48–72 hours of treatment Persistent hearing loss Difficulty balancing or dizziness Signs of complications, like facial paralysis or mastoid tenderness © What patient education is essential for the patient with otitis media? The proposal of “watchful waiting” requires providers educate parents and caregivers about expected course of the condition. Parents need to be aware of both supportive management, such as pain management, and situations requiring upgrading to more aggressive intervention. Parental comfort with delaying antibiotic administration may be increased with provision of a written antibiotic prescription to be held while the child is under initial observation. caregivers often require careful explanation about symptomatic treatment rather than antibiotic treatment in the absence of AOM. Antibiotic treatment alone does not necessarily relieve pain and sleeplessness Pain relief measures are necessary whether or not the provider is waiting to initiate antibiotics OM, including AOM and OME, is not contagious, allow children to return to day care or school once acute symptoms have resolved. All caregivers need to understand proper administration of antibiotics and management of pain and other symptoms. Teachers need to be aware of impaired hearing, which may continue for weeks or months after the acute infection stage. Nose © Discuss the pathophysiology of rhinitis. When an allergen is inhaled, the IgE attached to the mast cells within the mucosa and submucosa stimulates the release of histamine and leukotrienes, causing local tissue edema and increased drainage © What differential diagnoses are essential when considering rhinitis in a patient? Primary Differentials: nasal-septal trauma, substance use (e.g., cocaine, heroin), granulomatosis with polyangiitis (i.e., Wegener granulomatosis), sarcoidosis, polyposis, and intranasal masses or tumors Exclude structural abnormalities within the nasopharynx, irritant exposure, pregnancy, hypothyroidism, idiopathic rhinitis, rhinitis medicamentosa, or prolonged use of topical α-adrenergic agents before considering a diagnosis of AR © List subjective and objective data for the patient with rhinitis. List the pharmacological management for the patient diagnosed with rhinitis. © Rhinitis © Cause © Duration © Subjective Data © Objective Data © Treatment © Contagious © Allergen exposure © Depends on © Sneezing © Pale/bluish nasal © *Intranasal © Not contagious © Pollen allergen © Nasal congestion mucosa corticosteroids © Triggered by © Dust exposure © Clear discharge © Clear nasal © PO allergens © Allergic Rhinitis © Mold © Seasonal © Itchy nose/eyes discharge Antihistamines © Pet dander © Year-round © Triggered by © Swollen turbinates © Allergen allergens avoidance © Nasal irrigation © Viral infection © Typically 7 - 10 © Nasal congestion © Nasal mucosa © Supportive care © Highly © Rhinovirus days © Clear or slightly appears © Hydration contagious © Coronavirus © Mild improvement mucopurulent erythematous (red) © Rest © Respiratory © Influenza) after 3-4 days discharge and swollen. © Saline irrigation droplets © Sneezing © Clear or slightly © Decongestants © Close contact © Viral Rhinitis © Sore throat, mucopurulent © Analgesics often due to nasal discharge. postnasal drip © No sinus © Fatigue and tenderness or malaise localized facial pain on palpation.  © Low-grade fever © No significant (if present) findings in the © Symptoms are throat other than limited to the mild erythema (due nasal passages to postnasal drip). and throat © No fever or, if © History of sick present, it is contact typically low- grade. © Normal lung sounds on auscultation © Environmental © Chronic or © Nasal congestion © Erythematous © Avoidance of © Not contagious irritants intermittent © Sneezing nasal mucosa irritants © Triggered by © Smoke © Symptoms may © Triggered by © Absence of © Nasal irrigation irritants or non- © Non-Allergic Rhinitis © Odors persist as long as irritants purulence © Intranasal infectious © Weather changes irritants are © No allergen © Normal findings corticosteroids factors © Hormones present exposure history © Supportive care © Bacterial infection © >10 days © Nasal congestion © Nasal congestion © Antibiotics © Less contagious © Streptococcus © May worsen after © Purulent © Purulent (yellow- © Augmentin than viral pneumonia initial (yellow-green) green) nasal (amoxicillin- © Usually © Haemophilus improvement nasal discharge discharge clavulanate) secondary influenzae (double- © Mild to moderate © Mild to moderate © Saline irrigation infection worsening) facial discomfort, facial discomfort, © Decongestants if present if present - but (short-term) © Symptoms limited not localized over © Analgesics to the nasal specific sinuses passage © Symptoms are © Often no systemic limited to the symptoms, such as nasal passages and high fever do not involve the © Bacterial Rhinitis sinuses. © No significant sinus tenderness on palpation © No systemic symptoms such as high fever, though low-grade fever may occasionally occur © Normal lung sounds on auscultation © What patient teaching is essential for the patient with rhinitis? Once the environmental allergens have been identified, recommendations can be made and a therapeutic regimen agreed on. Education is crucial in the management of AR. A dramatic improvement in symptoms is often noted when patients become experts on the triggers that activate symptoms. An allergy diary is therefore often useful. Reducing exposure to dust mites, animal dander, molds, cockroaches, pollens, smoke, and other irritants is essential. Patients should also understand how to use nasal inhalers correctly and the importance of using inhalers regularly to promote their effectiveness. The side effect profile of these medications and of over the counter and prescription antihistamines and decongestants should also be discussed. © Are there complications for the patient with rhinitis? List. Increased asthma and other pulmonary disease exacerbations are related to rhinitis, and sleep apnea can be a problem in untreated rhinitis © Discuss pathophysiology and risk factors for epistaxis. Risk Factors: most commonly caused by trauma, dry air, anticoagulant use, or underlying vascular conditions Patho: can originate from the anterior nasal septum (Kiesselbach's plexus) or posterior nasal cavity (sphenopalatine artery), with anterior bleeds being more common and posterior bleeds being more severe © Discuss the management of a patient with epistaxis. Non-Pharm: Pinching the soft anterior part of the nose Sit upright Lean forward to prevent blood aspiration Applying ice packs to the nasal bridge to constrict blood vessels Pharm: First-line options: Nasal saline sprays to maintain mucosal hydration Topical vasoconstrictors such as oxymetazoline to control active bleeding Alternate options for recurrent or severe cases: Silver nitrate cauterization of the bleeding site Nasal packing for persistent bleeding Referral for arterial embolization in refractory cases © Discuss patient education for the patient with frequent epistaxis episodes. Once the bleeding has stopped, avoid vigorous exercise and aspirin-containing medications for several days or weeks Call the healthcare provider if the bleeding recurs (particularly while packing is in place) Avoid: tobacco, hot and spicy foods, nasal trauma, and digital self-trauma Lubricate the mucous membranes with petroleum jelly, nasal saline, or bacitracin ointment may relieve nasal discomfort and reduce the need to manipulate the nasal passages Humidification may also prevent the nasal irritation that results from a dry environment Apply firm pressure to the nostrils for 10-30 minutes © Are there complications associated with chronic epistaxis? Respiratory function can be compromised, and patients may become hypotensive or anemic if bleeding is severe Other complications are usually related to treatment and include necrosis, abscess formation, septal perforation, and sinus infection Toxic shock syndrome has also been reported as a complication of nasal packing; thus, appropriate antibiotic therapy may be prescribed at the discretion of the provider while the packing is in place Posterior packing can cause a vagal response resulting in hypotension and bradycardia patients who undergo embolization are at higher risk for a stroke © Differentiate between a patient with rhinitis and one with sinusitis. Sinusitis typically presents with facial pain and pressure and headache © What element is key in making the diagnosis of sinusitis? duration of symptoms (typically 7–10 days), the nature of nasal discharge (clear or mucopurulent), and the presence of systemic symptoms like fatigue or mild fever Assess for nasal congestion, mucosal swelling, and sinus tenderness during the physical exam © Provide education to a patient on the proper way to use nasal steroids. Throat © What differential diagnoses should we consider when caring for a patient with suspected pharyngitis? bacterial pharyngitis, mononucleosis, or aphthous ulcers © Discuss key findings that assist the APRN in distinguishing between bacterial and viral pharyngitis. Fever is typically present with bacterial pharyngitis signs of bacterial infection: tonsillar swelling, exudates, and petechiae on the soft palate © Discuss the pharmacological management of caring for a patient with viral and bacterial pharyngitis. Viral: Analgesics for sore throat or fever: PO Tylenol (acetaminophen) PO Advil (ibuprofen) Cough suppressants for associated cough: PO Delsym (dextromethorphan) Throat lozenges or sprays containing mild anesthetics (e.g., benzocaine) to soothe throat discomfort Bacterial: First-line Antibiotic Therapy: PO Penicillin VK (penicillin V) 500 mg 2–3 times daily for 10 days PO Amoxil (amoxicillin) 500 mg twice daily for 10 days Antibiotics for Penicillin Allergy: PO Keflex (cephalexin) 20 mg/kg/dose twice daily (max 500 mg/dose) for 10 days PO Cleocin (clindamycin) 7 mg/kg/dose thrice daily (max 300 mg/dose) for 10 days PO Zithromax (azithromycin) 500 mg on day 1, followed by 250 mg once daily on days 2–5 Analgesics/Antipyretics for Fever and Pain: PO Tylenol (acetaminophen) PO Advil (ibuprofen) Throat lozenges or sprays containing anesthetics (e.g., benzocaine) for localized relief © What diagnostics are available for use when suspecting pharyngitis in a patient? No specific diagnostic test exists for viral pharyngitis Group a step infection includes a throat culture, a rapid antigen detection test (RADT), and sometimes an antistreptolysin O (ASO) titer © List the common complications with pharyngitis. Chronic tonsillitis: upper airway obstruction, sleep apnea, and sleep disturbances Acute streptococcal infections: Suppurative: streptococcal pharyngitis, otitis media, sinusitis, impetigo, pneumonia, and necrotizing fasciitis Nonsuppurative: ARF and poststreptococcal glomerulonephritis © Discuss scenarios that would prompt a referral for a patient with pharyngitis. To whom should they be referred? bacterial: Immediate follow-up or referral is necessary for: Symptoms persisting beyond 48–72 hours despite antibiotics. Development of new symptoms, such as severe dysphagia, neck swelling, or respiratory distress (possible abscess or epiglottitis). Signs of systemic complications, such as rash or joint pain (possible rheumatic fever). Viral: Immediate follow-up or referral is necessary for: Symptoms persisting beyond 10 days Severe throat pain or dysphagia High fever or neck swelling (potential bacterial infection or abscess) © List subjective and objective data present in a patient with infectious mononucleosis. Subjective: Fatigue - Severe and persistent, lasting weeks Sore throat - Often severe, with difficulty swallowing Fever - Low to moderate grade Swollen glands - Particularly in the neck (posterior cervical lymphadenopathy) Malaise and body aches - Common systemic symptoms  Denies sneezing, runny nose, and cough - Helps differentiate mono from viral respiratory infections (e.g., colds or flu) Duration - Symptoms typically last 2–4 weeks, though fatigue can persist longer Objective: Inspection of the pharynx: Tonsillar hypertrophy with or without exudates - See image above for exudates related to mono Pharyngeal erythema Possible petechiae on the soft palate Physical Exam Posterior cervical lymphadenopathy - Bilateral, tender, and enlarged nodes in the neck Splenomegaly - Enlarged spleen in 50% of cases, best assessed by palpation or ultrasound Hepatomegaly - Occasionally present, with mild liver tenderness Skin rash - May occur, mainly as a cross-reaction, if antibiotics like amoxicillin or ampicillin are mistakenly prescribed for presumed bacterial pharyngitis © List complications of infectious mononucleosis. Acute upper airway obstruction, hepatomegaly, splenomegaly, and splenic rupture © Discuss the pathophysiology of aphthous ulcers. Exact cause of these ulcers is unknown, it is thought to be autoimmune in nature © List factors that put a patient at risk for aphthous ulcers. physical or emotional stress; trauma associated with physical, chemical, or local agents; deficiencies of vitamin B12, folic acid, or iron; familial or genetic predisposition; microbial agents; and hypersensitivity states such as gluten-sensitive enteropathy © Discuss the clinical presentation in the patient with aphthous ulcers. This would be our subjective and objective data. Subjective: Painful, round, or oval ulcers with a white or yellow center and a red border Objective: Round or oval ulcers on the inner cheeks, lips, or tongue Surrounding mucosa may appear normal or slightly erythematous © Discuss the recommended treatment for patients with aphthous ulcers. Non-Pharm: Good oral hygiene - Encourage regular brushing and flossing while avoiding harsh toothpastes or mouthwashes. Avoid irritants - Refrain from consuming spicy, acidic, or abrasive foods Saltwater rinses - Gargling with warm salt water can reduce inflammation and promote healing Hydration - Ensure adequate fluid intake to prevent dryness and further irritation Pharm: Topical Anesthetics: Anbesol or Orajel (benzocaine gel): Applied directly to ulcers to reduce pain and discomfort Anti-inflammatory Treatments - Topical Corticosteroids (for severe or recurrent cases): Decadron (dexamethasone elixir 0.5 mg/mL): Swish and spit, four times daily for 7 days Kenalog in Orabase (triamcinolone dental paste): Applied directly to ulcers for localized anti-inflammatory effects Prevention of Secondary Infections - Antiseptic Mouthwashes: Peridex or Periogard (chlorhexidine gluconate 0.12%): Rinse twice daily to prevent secondary bacterial infections and promote healing © Discuss patient teaching essential for patients diagnosed with aphthous ulcers. Patients should be educated about potential triggers, treatment options, and preventive strategies Avoidance of irritating food, beverages, and chemicals may alleviate some of the symptoms and decrease the number of recurrences