PRESENTER Mrs.TUIKUBULAU/Mrs.

Mackay 01/08/2011

 Upon

completion of this session, you should be able to: Define key terms. Identify the subjective and objective data when assessing the conditions affecting the EENT. Discuss the nursing care for the patient with common EENT problems.

SUBJECTIVE DATA STRUCTURE - EYE Vision difficulty(decrease acuity, blurring, blind sports. Pain Strabismus, diplopia Redness, swelling Watering, discharge History of ocular problems Uses of glasses/contact lenses Self care behavior.

Preparation Equipments needed Snellens eye chart Opaque card /occluder Penlight Applicator stick Ophthalmoscope

 Facial

and ocular expression Eye lids & Conjunctiva

Lacrimal Sclera

system

Cornea

----Prominence of eyes: alert or dull expression. __Symmetry, presence of edema, ptosis, itching, redness, discharges, blinking, equality, growth. ___Tears, swelling, growth ___Color ___Clarity

Anterior chamber Iris & pupils Pupillary reflex light

__Depth, presence of blood/pus __Irregularities in color, shape , size __Constriction of pupil in response to light in that eye (direct light reaction);equal amount of constriction in the other eye (consensual light reaction)

Accommodation

Lens Peripheral vision

__Convergence of eyes and constriction of pupils as gaze shifts from far to near object __Transparent or opaque __Ability to see movements & objects well on both sides of field of vision Ability to read newsprint, clocks on wall, & recognize facesb/side/door Glasses, contact lenses, prosthesis.

Acuity with or without glasses Supportive aids

Test Central Visual Acuity Snellen Eye Chart (SEC) Place a Snellen chart 2o feet

INJURY
Burns: Chemical, Flame

INTERVENTIONS
Flush eye immediately for 15 min with cool water Seek Medical assistance Lift upper lid over lower lid to dislodge substance, produce tearing; Irrigate eye with water. Obtain Medical assistance if intervention fail. Apply cold compression if no laceration present. If laceration present-Seek medical assistance. Do not remove object; Place protective shield over eye/cover uninjured eye to prevent excess movement of injured eye.

Loose substance on conjunctiva: Dirt, Insects

Contact injury: Contusion, Ecchymosis, Laceration

Penetrating objects

DISORDERS
Hordeolum (style)

DESCRIPTION
Infection Lid margins; swollen pustules, resolves/ruptures.

COLLABORATIVE MANAGEMENT
Warm compression 34 per day. Antibiotic ointments if severe

Trachoma

A chronic infectious Early treatment with form of conjunctivitis antibiotics. . Administer antibiotics& corticosteroids

Corneal ulcer

 Inflammation

conjunctiva Collaborative care management Careful cleaning of the eye lids and lashes by warm compression Application of topical antibiotics e.g. Tetracycline eye oint/chrolophenicol eye drop

of the

1.

2. 3. 4.

5.

Use sterile technique - infection or ulceration clean technique - Allergic reaction. Separate equipment- bilateral eye infection Wash hands before treating each eye. Temperature of compress should not be more than 49 deg cent (120 deg fer) Change compression frequently(5min) Wash hands first

6.
7.

Do not exert pressure on the eyeball. I f sterility is not required, moist heat may be applied by means of a clean face cloth.

 Teach

about disease and its treatment Patient to avoid crowded environments & keep hand away from face. Frequent hand washing(Before & after treatment) Instruct pt correct technique of instilling ophthalmic ointment( inner to the outer canthus).

 Clouding

/opacity of lens that leads to painless blurring & loss of vision. Nursing Management Preoperative care Eye lashes may be cut(Eye depart) Dilatation of the pupil operative eye (mydriacyl eye drop)

Postoperative care

Position pt supine /unoperated side Vital sign-4 hrly (TPR,B/P) Eye dressing- Keep dressing intact(metal dressing). Administer pain medication Call light- Within reach/Bedside table unoperated eye. Avoid stress activity e.g. Increase Intraocular pressure(IOP) (sneezing, vomiting, coughing, straining)

Patient/Family education Medication (>2 , wait 2-5 min, ointment last) Avoid lifting heavy object, active exercise, straining-defecation Review date.

 SUBJECTIVE

DATA

Ear

aches Infections Discharges Hearing loss Environmental noise Tinnitus Self care behavior

Inspect & Palpate the External ear Size & shape Skin condition Tenderness External auditory meatus Inspect -otoscope

Inspect

otoscope Pull the pinna up & back(straightens S shape-canal) Hold the otoscope & inspect Note any redness, swelling,lesions, f/b, discharge.

Whispered Voice Test

Test one year at a time: 1-2 ft from pts ear whisper 2 syllable word-Tuesday-pts to repeat.
Test hearing by Air conduction (AC) or by Bone conduction(BC).

Tuning Folk (TF)Tests

Weber Test (Hearing better with one ear than the other)

Place a vibrating TF midline of the persons skull- tone sounds the same /equally loud in both ears.
Place the stem of the vibrating TF persons mastoid processsignal sound goes away; quickly invert the fork-vibrating end near the ear canal-still hear a sound. (N- AC >BC).

Rinne Test (Compares AC & BC sounds)

 ASSESSMENT

Objective

Subjective

data Pain-severe & throbbing Sense of fullness/pressure in the ear Change in hearing

data Inflamed, budging tympanic membrane Drainage ear: bloody, serous, purulent Perforation tympanic membrane Fever

N/diagnosis Pain due to buildup of fluid in ear spaces, swelling, trauma. Knowledge deficit: treatment of otitis ,self care after ear surgery.

Intervention Administer medications e.g. Paracetamol, Antibiotics as prescribed. Instruct the pt to avoid getting water in the ear during treatment. Teach pt/family on ear wash Minor earache & discomfort cheek &jaw are common-managed by analgesia.

Evaluation Pt states that no pain is present

Has no ear drainage, no redness edema, itching. Ear canal is clean & healed.

 SUBJECTIVE

DATA

Discharge
Frequent

colds(upper respiratory infections) Sinus pain Trauma Epistaxis Allergies Altered smell

Equipment Needed Otoscope-short wide tip nasal attachment Penlight 2 tongue blades Gloves Cotton gauze pad

Inspect and palpate :symmetric ,midline in proportion to other facial features Inspect for any deformity, asymmetry, inflammation, or skin lesions Palpate for any pain/break in contour. Palpate the sinus areas-Tenderness

Inspect with penlight: Lips, teeth, & gums, tongue, buccal mucosa- note color: lesions. Palate & uvula- Note integrity & mobility as person phonates Inspect tonsils Pharyngeal wall- Note color, exudates /lesions Palpate lesions

Nosebleed Collaborative nursing care

 Jarvis,C.,

(2008). Physical examination & health assessment(5th ed). St Louis, Missouri: Saunders, Elsevier. Phipps, W. J., Sands, J.K.,& Marek, J.F. (1999). Medical-surgical nursing: concepts & clinical nursing. (6th ed). St Louis: Mosby.