Download NUR 611 Adv Practice Nursing 1 NUR_6111_Week_4_Eye, Ear, Nose, and Throat. and more Exams Nursing in PDF only on Docsity!
● Ophthalmic Disorders ○ Conjunctivitis ■ conjunctiva is the transparent mucosal tissue that lines the eye and inner surface of the eyelids ■ Conjunctivitis is a broad term for a group of conditions that result in swelling, inflammation, or infection of the conjunctiva ■ This inflammation can be hyperacute, acute, or chronic in presentation ■ Conjunctivitis can be bacterial, viral, or allergic. ■ Commonly referred to as “pink eye.” ■ ■ ■ Viral ● 70% of all infectious cases are viral ○ 65-90% is caused by adenovirus (common cold) ● Other viral agents: herpes simplex virus (HSV), rubella, measles, varicella-zoster (chickenpox/shingles), Epstein-Barr (mononucleosis) and Molluscum contagiosum (pox virus) ● It lasts 5-14 days ● Contagious as long as they are tearing for at least 1 week ● Through the tears is where the shedding viral particles are spread. ■ Viral Clinical Presentation/Chief Complaint ● Recent URI (spread through coughing) or exposure to sick contacts ● Ocular s/s: onset of red eye, excessive watery discharge, burning/itching, photophobia, watering, and foreign body sensation ● Classically, it begins in one eye and then involves the other eye within a few days ● Patients are usually able to recall the precise moment symptoms began
● Approximately 50% of the patients will have bilateral involvement ● It resolves spontaneously after 1-2 weeks ■ Viral Treatment ● VIRAL: self-limiting & resolves after 5-14 days and treatment is supportive ● Pharmacological ○ No longer recommend antibiotic treatment prophylactically to prevent a bacterial infection ○ Antihistamine/decongestant drops ● Non-pharmacological ○ Supportive ○ Ocular decongestants ○ artificial tears ○ cool compresses ● REFER TO OPHTHALMOLOGIST IF S/S DO NOT RESOLVE AFTER 7-10 DAYS OR WITH CORNEAL INVOLVEMENT ■ Bacterial ● Acute conjunctivitis is the most common bacterial infection. ○ Adults: typically, Staphylococcus aureus is most common. ○ Children: typically Haemophilus influenzae and Streptococcus pneumoniae. ■ Bacterial Clinical Presentation/Chief Complaint ● Most commonly, spreads through direct contact with contaminated fingers ● Can be categorized as hyperacute, acute, or chronic based on s/s ○ Hyperacute : associated with gonorrhea in sexually active adults ■ S/S: copious, purulent yellow or green discharge, pain, & diminished vision loss; both eyes are “sticky or glued shut”, worse in the morning ■ Sudden onset and rapid progression ○ Acute : most common form of bacterial conjunctivitis (S. aureus) ■ S/S: persist for less than 3-4 weeks ○ Chronic : s/s that persist for at least 4 weeks with frequent relapses ■ Refer to ophthalmologist ■ Bacterial Treatment - Mild to Moderate ● Primary ○ azithromycin ophthalmic drops 1% (AzaSite) ■ 1 drop BID x 2 days, then 1 drop daily x 5 days ○ erythromycin ophthalmic ointment 0.5% (Ilotycin) ■ Apply 1cm ribbon to the affected eye up to 6x a day for 7-10 days
■ Start topically with supportive care and artificial tears, cool compresses, and remove contacts ■ If s/s persists, add an antihistamine-vasoconstrictor with caution to be used for less than 2 weeks (rebound vasodilation can occur, resulting in med-induced conjunctivitis) ■ Antihistamines with Mast cell stabilizers can be used as prophylactic treatment for recurrent or persistent conditions (Xatador, Patanol, Pataday) ● ○ **Photophobia can either be direct, consensual, or both. Direct photophobia refers to pain with light shining in the affected eye, whereas consensual photophobia refers to pain with light shining in the unaffected eye ■ ● Considerations - viral/bacteria ○ Anyone with a confirmed infection must not work or attend school until the symptoms resolve, which can take 3 to 7 days. ● Referral ○ Ophthalmologist
○ Decrease in vision/visual problems ○ Eye pain ○ Photophobia ○ Fixed or sluggish pupils ○ Severe purulent drainage ○ Corneal involvement ○ Recent trauma ○ Recent ocular surgery ○ Use of contact lenses ○ No response, treatment, or worsening symptoms ○ Recurring symptoms ○ Suspected herpetic infection (hx. HSV infection or rash involving dermatome) ● Education/Prevention ○ Identify the underlying cause ○ HAND HYGIENE!!*** (antimicrobial soap) ○ Throw away any old contact lenses, solutions, & holders. ○ Clean glasses ○ Wash any bedding or sheets ○ Do not wear contact lenses during acute infection ○ Ointments may cause blurry vision ○ Avoid touching their eyes ○ Avoid shaking hands with others ○ Avoid sharing towels or bedclothes ○ Avoid swimming in pools ○ Glaucoma ■ ■ Acute closed-angle (closed angle, narrow-angle) ● A sudden, marked increase in intraocular pressure ● More prevalent in Asians and Eskimos ● Sudden onset vision loss, rapid peripheral vision loss, then central ● Poorly reacting pupils, fixed & mid-dilated pupils that look more oval ● Sudden onset of headache, blurry vision, tearing, halos, nausea & vomiting ● Emergency – refer to ED ● Congenital
● 1-2 gtts into affected eyes BID ● Secondary ○ Alpha-2 adrenergic agonist ■ apraclonidine (Lopidine) ■ brimonidine (Alphagan P) ● 1 gtt to affected eye 3x/day ● Tertiary ○ Cholinergic agonist ■ pilocarpine (Vuity) ● 1 gtt into the affected eye 4x a day ■ Non-Pharmacological ● Optic nerve changes/Treatment failure ○ Laser tx to reduce intraocular pressure ○ Several methods ○ Patients may still require ongoing topical ophthalmic therapy ● Treatment Failure/Rapidly progressing disease ○ Surgery is done to facilitate aqueous humor outflow ■ Medications and Glaucoma ● The use of steroids (cortisone-like medications) can cause elevated eye pressure and open-angle glaucoma in some individuals. ● Many medications can cause narrow-angle glaucoma in people who are predisposed to this condition. ● Over-the-counter medicines such as decongestants and antihistamines can dilate the pupil and lead to dangerously elevated eye pressure. ● Prescription medications for bladder incontinence, motion sickness, certain psychiatric medications, diet pills, and some sulfa-derived medications can cause angle closure glaucoma. ● Use topical β-adrenergic blockers with caution in patients already on oral β-adrenergic blockers and in patients with COPD, asthma, & cardiac conditions ● Do not recommend antihistamines to patients with narrow-angle glaucoma. ● Always check with your ophthalmologist before starting new medications if you have glaucoma ○ Macular Degeneration ■
■ Age-related macular degeneration ● most common cause of permanent vision loss in older adults ● More common in smokers ● Atrophic or dry form—more common, “less severe” ● Wet form is responsible for 80% vision loss ● Symptom: Loss of central vision over years ● The first sign is scotoma (blind spot) ● Peripheral and color visions are normal ● Refer to ophthalmologist ● Tx: d/c smoking, “AREDS” ocular vitamins (high zinc and antioxidants) ● Ear Disorders ○ Otitis Externa (OE) ■ OE is an inflammation or infection of the external auditory canal (EAC), the auricle, or both. ■ Swimmer’s ear ■ Most common cause: S. aureus and P. aeruginosa ■ ■ Signs & Symptoms ● Key Finding : pain upon palpation of the tragus (anterior to the ear canal) or application of traction to the pinna (the hallmark of OE). ● Patients may also have the following signs and symptoms: ○ Otalgia - Ranges from mild to severe, typically progressing over 1-2 days ○ Hearing loss ○ Ear fullness or pressure ○ Erythema, edema, and narrowing of the canal ○ Tinnitus ○ Fever (occasionally) ○ Itching (especially in fungal OE or chronic OE) ○ Severe deep pain - Immunocompromised patients may have necrotizing (malignant) OE ○ Discharge - Initially clear, it quickly becomes purulent and foul-smelling ○ History of exposure to or activities in water (frequently) (eg, swimming, surfing, kayaking) ○ History of preceding ear trauma (usually) (eg, forceful ear cleaning, use of cotton swabs, or water in the ear canal)
■ A diagnosis of acute otitis media requires: ● History of acute onset of signs and symptoms ● Presence of middle ear effusion ● Signs and symptoms of middle ear inflammation. ■ Most are viral. ■ When bacterial S. pneumoniae, H. influenzae, and M. catarrhalis ■ Key features include: ● Bulging tympanic membrane ● Reduced mobility of the tympanic membrane when pneumatic pressure is applied ■ ■ Treatment - Suspected AOM (Symptoms less than 3 days) ● **Most likely viral. ● Primary ○ Acetaminophen ○ Ibuprofen ● NON-PHARM ○ Heat ○ Myringotomy with or without tubes, if persistent or chronic ■ Antibiotic Management ● If symptoms worsen or do not improve in 3 days. Treat for 5- days normally and 10 days for severe. ○ Amoxicillin (Amoxil) 500 mg TID or 875mg BID (maximum 4000mg/day) ○ Amoxicillin/clavulanate (Augmentin) PO 500 mg/125 PO TID or 875 mg/125 mg BID x ● PCN Allergy ○ Cefdinir (Omnicef) 300 mg orally twice daily or 600 mg once daily. ○ Cefuroxime (Ceftin) 250- 500 mg orally, twice daily.
○ Azithromycin PO 500mg OD x 5 days ● *improvement within 48-72 hours; if not, consider switching to 2nd line ● *start with the 2nd^ line if symptoms are severe, recent antibiotic use (3 months) ● Upper Respiratory Infection ○ Allergic Rhinitis ■ Presumptive dx may be made in the presence of nasal congestion, sneezing, and itchy nose/palate/eyes with a pattern of allergic triggers. ■ Definitive dx requires specific IgE reactivity. ■ ■ Physical Findings ● Allergic shiners ● Conjunctival injection ● Pale, boggy turbinates, clear nasal secretion ● Allergic salute ● Mouth breathing, dry lips ● Lymph nodes ● Cobblestone appearance in pharynx and tonsils – chronic allergies ■ Pharmacologic Management ● Saline nasal spray ● Nasal steroids (strong recommendation) ○ flonase 50 mcg/spray 1-2 sprays per nostril daily ○ beclomethasone ● Antihistamines (strong recommendation) ○ 1 st^ generation (drowsy) – Diphenhydramine 25 mg – 50 mg q 4- 6 h max 300 mg ○ 2 nd^ generation (less drowsy) ■ Cetirizine (Zyrtec) 5 – 10 mg OD ■ levocetrizine (Xyzal) 5 mg OD ■ loratadine (Claritin) 10 mg OD ■ fexofenadine (Allegra) 180 mg OD ● Nasal anti-histamine (option) - Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic allergic rhinitis ○ Patanase 2 sprays BID ■ Management
● An assessment tool to evaluate the probability of acute GAS infection. ○ 3-4 points: treat empirically for strep ○ 2 points: RADT, and treat If positive ○ 1 point: Strep infection is unlikely ○ 0 to 1 point: No test or treatment is needed ● ■ ■ Non-pharmacologic ● Gargling with warm salt water ● Increase fluids ● Patient education regarding disease, course, and treatment ■ Pharmacologic ● Antipyretics/analgesics for fever and throat pain ● Primary ○ Penicillin G 1.2-million-unit IM injection ○ Penicillin V potassium (Pen VK) 500 mg BID-TID x 10 days. ○ Amoxicillin 500 TID or 875 mg BID x 10 days ● Secondary (PCN allergy or resistance) ○ Azithromycin (Z-Pack) ○ Clarithromycin (Biaxin) 250 mg q12h x 10 days ○ Cephalexin (Keflex) 500mg BID for 10 days ○ Clindamycin 300 mg q8h x 10 days ○ Rhinosinusitis ■ Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity & paranasal sinuses.
■ Uncomplicated rhinosinusitis is defined as rhinosinusitis without clinically evident extension of inflammation outside the paranasal sinuses & nasal cavity when diagnosed ● < 4 weeks = Acute ● 4-12 weeks = Subacute ● Chronic = > 12 weeks ■ Pathophysiology ● The most common cause of ARS is viral and related to an upper respiratory tract infection (URI) ● Most sinus infections involve the maxillary and anterior ethmoidal sinuses ● The maxillary sinus is the largest of the paranasal sinuses and its ostium into the nose is superiorly placed ● ■ Etiology/Risk Factors ● Allergies ● Asthma ● Tooth Abscess/dental infections/procedures ● Cigarette Smoking ● Swimming in contaminated water ● Conditions that cause swollen nasal mucous membranes, such as the common cold or allergic rhinitis ● Anatomical abnormalities (nasal polyps + deviated septum) ■ Symptoms ● URI symptoms, - Postnasal drip (often with a bad taste), cough (especially when in a prone position), congestion, fever, ear fullness/pressure, sore throat from nasal drip ○ Hyposmia/anosmia ● Fatigue ● 3 cardinal symptoms: purulent nasal discharge, nasal obstruction, and facial pain/pressure/fullness ● Acute frontal sinusitis causes pain in the forehead and above eyebrows ● Maxillary sinus infections produce pain and tenderness over the cheek (toothache)
○ It should only be done on patients with severe headache, facial swelling, or cranial nerve palsies ● CT of the sinuses should be performed only after completing maximal medical therapy or with those who have orbital complications, neurological defects associated with sinusitis, or those who are immunodeficient ■ Symptomatic Treatment ● Analgesics, intranasal corticosteroids, and saline nasal irrigations are options for the management of rhinosinusitis symptoms ● NSAIDS or acetaminophen can be recommended for treatment of fever, facial pain, or headache ○ acetaminophen 650 mg PO every 4-6 hours PRN ○ ibuprofen 400mg-800mg PO Q-8 hours PRN ● Intranasal steroids such as fluticasone have been shown to improve symptoms ○ Fluticasone (Flonase) 1 spray in each nostril BID ● Saline nasal irrigation is shown to improve mucociliary clearance and may be beneficial, ie: Neil Med ● Decongestants and antihistamines are not shown to be effective as treatment for bacterial sinusitis ■ Non-Pharmacological Treatment ● If the patient exhibits signs of viral sinusitis, “watchful waiting” is advised before treatment with antibiotics ● Educate the patient to avoid environmental irritants ● Manage allergic rhinitis to prevent sinusitis ● Use of humidified air to improve mucous clearance ● Increase fluid intake ● Sleep with head elevated to allow for mucous drainage ● Educate the patient on the disease process and reasons for not being prescribed antibiotics right away ■ Pharmacological Management ● Viral ○ Viral rhinosinusitis is a self-limited disease and does not need antibiotic treatment ○ Management is primarily directed toward symptom relief and avoidance of unnecessary antibiotics. ● Bacterial ○ Primary (treatment 5-7 days) ■ amoxicillin (Amoxil) 500mg PO TID or 875mg BID ■ amoxicillin/clavulanate (Augmentin) 500 mg/125 mg TID or 875 mg/125 mg BID (for failed tx 2000/125mg ER PO BID) ○ Secondary
■ doxycycline (Vibramycin) 100 mg PO BID or 200mg OD ■ Levofloxacin (Levaquin) 500mg PO QD ■ Clindamycin 300mg PO BID ○ Usually prescribed if a patient has had antibiotic use in the past month, moderate to severe symptoms, or co-morbid conditions ■ Referral ● Urgent early referral in patients with ○ high, persistent fevers >102°F ○ periorbital edema, inflammation, or erythema ○ cranial nerve palsies ○ abnormal extraocular movements, proptosis; vision changes (double vision or impaired vision) ○ severe headache ○ altered mental status ○ meningeal signs ○ Chronic Sinusitis (CRS) ■ **Often gets missed by healthcare providers ■ An inflammatory condition that has occasional, acute exacerbations ■ Polyps, edema, or purulent mucus are found on examination ■ There is usually an underlying condition ■ The presence of 2 or more of these signs and symptoms for >12 weeks is highly sensitive for diagnosing CRS ● Nasal obstruction ● Facial Congestion-pressure-fullness ● Discolored nasal discharge ● Hyposmia (decreased sense of smell) ■ Risk Factors ● About 1 in 5 people with CRS also have asthma --- CRS makes asthma worse ● Allergies - especially allergies that are present year-round & are poorly controlled, such as dust mites, animal dander, molds, & cockroaches. ● Exposure to tobacco smoke or airborne irritants ● Patients who have cystic fibrosis, immunodeficiency, & ciliary dyskinesia ● A deviated septum – is a common cause of nasal blockage. It may cause 1 nostril or sometimes both nostrils, to be blocked ● Viral infections – Some people develop CRS after having repeated viral infections (such as the common cold) ■ Management ● Treatment ○ Focus on treating the underlying cause
