Acute Otitis Media

o The most common problem of the middle ear.

o Usually a childhood disease associated with colds, allergies, sore throats, and blockage of the
Eustachian tube.
o Risk factors are: young age, congenital abnormalities, immune deficiencies, exposure to
cigarette smoke, family history, male, recent URI
o Collaborative Care:
o Antibiotics (Amoxicillin for 10 days
o Surgical intervention is generally reserved for the patient who does not respond to
medical treatment
o Myringotomy involves to release the increased pressure and exudate from the middle
ear
o In the adult patient for whom allergy may be a causative factor, antihistamines

Chronic Otitis Media
Clinical Manifestations
o Its characterized by a purulent, mucoid, or serous discharge accompanied by hearing loss and
occasionally by ear pain, nausea, and episodes of dizziness.
o Occasionally a facial palsy or an attack of vertigo may alert the patient to this condition. Chronic
otitis media is usually painless, but if pain is present, it indicates that fluid has accumulated.
Complication
o Untreated conditions can result in perforation of the tympanic membrane and the formation of
a cholesteatoma (an accumulation of keratinizing squamous epithelium in the middle ear)
o In addition, hearing loss, facial paralysis)
Diagnostic
o Otoscopic examination
o Culture and sensitivity of middle ear drainage
o Mastoid x-ray
Collaborative Therapy
o Ear irrigations
o Acetic acid (equal amounts of white vinegar and warm water)
o Otic drops, powders
o Analgesics
o Systemic antibiotics
o Surgery
o Tympanoplasty: diseased tissue is removed, and the ossicles are examined and
evaluated in reconstructing the conductive mechanism.
Procedure to repair tympanic membrane rupture
o Mastoidectomy; is often performed with a tympanoplasty to remove diseased tissue
and the source of infection.













Otosclerosis
o An autosomal dominant disease, is the fixation of the footplate of the stapes in the oval
window.
o Otosclerosis is a condition affecting the stapes bone. A normal stapes bone moves like a small
piston; sounds cause the piston to vibrate. In otosclerosis, a callus of bone accumulates on the
stapes creating a partial fixation. This limits the movement of the stapes bone, which results in
hearing loss
o It is a common cause of conductive hearing loss in young adults, especially women, and may
accelerate during pregnancy.
o Spongy bone develops from the bony labyrinth, causing immobilization of the footplate
of the stapes, which reduces the transmission of vibrations to the inner ear fluids.
o The pt is often unaware of the problem until the loss becomes so severe.
Diagnostic
o Otoscopic examination may reveal a reddish blush of the tympanum (Schwarts sign)
o Rinne test, bone conduction will be better than air conduction if hearing loss is greater that 25
dB.
o Weber test lateralizes to the ear with the greater conductive hearing loss.
o Audiogram demonstrates good hearing by bone conduction
o Tympanometry
Collaborative Care
o Hearing aid
o Surgery (Stapedectomy); do the worse ear first then 6 months- 1 yr do the other ear.
o A prosthesis made stainless steal completes the ossicular chain. Sound is the conducted
with the prosthesis. During surgery the patient will often report an immediate
improvement in hearing in the operative ear. Because of accumulation of fluid.
o Postoperatively, the pt may experience dizziness, nausea, and vomiting as a result of
stimulation of the labyrinth intraoperatively.
o Some pt demonstrate nystagmus on lateral gaze because of disturbance of the
perilymph
o Drug therapy; these are to retard bone resorption and encourage calcification of bony lesions.
o Sodium fluoride
o Vitamin D
o Calcium carbonate














Malignant Melanoma
o Is a tumor arising in cells producing melanin, usually the melanocytes of the skin.
o This is the most deadly skin cancer
Superficial spreading
melanoma (SSM)
Most common, most curable. It
frequently arises from a
preexisting mole.
Often occurs on chronically
sun-exposed areas such as the
legs and upper back.
Lentigo maligna melanoma
(LMM)
Lesions appear as flat, brown,
irregular patches. These
patches increase in size for
many years before cancer
develops.
Commonly located on the face
and is often found on elderly
patients.
Acral lentiginous melanoma
(ALM)
More common in Asian and
dark people.
Appears on the soles, palms,
mucous membranes, and
terminal phalanges
Nodular melanoma (NM) Misdiagnoses because it looks
like a blood blister or polyp.
More aggressive type of
melanoma and invade rapidly.
Most common in men, and can
be located anywhere on the
body.

Clinical Manifestations
o More frequently on the lower legs in women and on the trunk, head, and neck in men.
o Often brown or black
Collaborative Care
o The initial treatment of malignant melanoma is surgery
o If the melanoma has spread you will need combination therapy. (Chemo and radiation)
o Cutaneous melanoma is nearly 100% curable by excision if diagnosed early when the malignant
cell are restricted.



















Psoriasis
o Chronic dermatitis, which involves excessively rapid turnover of epidermal cells
o Family predisposition
Clinical Manifestation
o Sharply demarcated scaling plaques of the scalp, elbows, and knees; palms, soles, and
fingernails possibly affected
o Localized or general, intermittent or continuous.
Treatment
o Aim of retarding growth of epidermal cells, usually topical corticosteroids.
o Antipsoriatics
o Antimetabolite
o Photochemotherapy
o Keratolytics
o Antimicrobial
o Avoid alcohol
o Treatments; bed cradle, daily soaks, and tepid, wet compresses
Nursing Management
o Administer UV light and PUVA therapy
o Apply occlusive dressings
o Prevent scratching
o Help the pt remove scales during soaks
o Identify ways to reduce stress
o Wear light cotton clothing over affected area
Hearing Loss and Deafness
o Deafness is often called the unseen handicap
Conductive Hearing Loss
o It occurs in the outer and middle ear and impairs the sound being conducted from the outer to
the inner ear. Its caused by conditions interfering with air conduction, such as impacted
cerumen and foreign bodies.
o The most common of conductive hearing loss is otitis media
o The pt may speak softly because he or she hears his or her voice, which is conducted by bone, as
being loud. This pt hears better in a noisy environment.
Sensorineural Hearing Loss
o Is caused by impairment of function of the inner ear or its central connections.
o The two main problems associated with sensorineural loss are the ability to hear sound but not
to understand speech, and the lack of understanding of the problems by others.
o They are not able to distinguish consonants or high pitched sounds. Words become difficult to
distinguish, and sound becomes muffled.
o Prebycusis, degenerative change of the inner ear, is a major cause of sensorineural hearing loss
in the older adult.
o If ototoxic drugs are used, hearing should be monitored frequently during treatment.
Mixed Hearing Loss: is a combination of conductive and sensorineural losses.
Central and Functional Hearing Loss
o Is caused by problems in the CNS from the auditory nucleus to the cortex.
o The pt is unable to understand or to put meaning to the incoming sound.
o Functional hearing loss may be caused by an emotional or a psychologic factor; no organic cause
can be identified.
Clinical Manifestations
o Congenital hearing loss
o Lack of response to auditory stimulation
o Impaired speech development
o Presbycusis
o Tinnitus
o Inability to understand the spoken word
Diagnostic Test
o Whisper test; reduced ability or inability to hear
o Rinne test; air conduction greater than bone conduction in sersorineural hearing loss; bone
conduction greater than air conduction suggests conductive loss
o Webers test; sound lateralizes to the better-functioning ear in sersorineural hearing loss; sound
lateralizes to the ear with the poorest hearing in conductive hearing loss
o Audiometry; hearing loss
o Tympanometry; impaired compliance

Nursing and Collaborative Management
o Hearing loss can be caused by acute loud noise (acoustic trauma) or by the chronic exposure to
loud noise (noise-induced hearing loss)
o Teaching on avoidance of loud noises
o Protectors can be worn
o Immunization
o MMR and Rubella
o Ototoxic Drugs
o Should be monitored.
o Some drugs are; salicylates, antimalarial drugs, diuretics, antineoplastic drugs, and
antibiotics
o The most common symptoms include tinnitus, sensorineural hearing loss, and vestibular
dysfunction
o Hearing Aids
o Speech reading
o Cochlear Implant
o Used as a hearing device for the profoundly deaf
o Placement of an electronic device that delivers electrical signals to the cochlear nerve to
create sound
o The system consists of a surgically implanted induction coil beneath the skin behind the
ear
o The ideal candidate is one who has become deaf after acquiring speech and language
o Extensive training and rehabilitation are essential to receive maximum benefit from
these impants.
Monitor and maintain position and patency of wound drainage tubes
Assess the patient for dizziness, nystagmus, and nausea
Antibiotics
Antivertigo agents
Antiemetic
Advance the pt diet, as tolerated
Avoid blowing the nose, sneezing, or coughing
Cover ears when outside

Burns
o Causes
o Radiation; X-ray, sun, nuclear reactions
o Mechanical; friction
o Chemical; acids, alkalies, vesicants
o Electrical; lightning, electrical wires
o Thermal; flame, frostbite, scald
o Cell destruction causes loss of intracellular fluid and electrolytes
Characteristic First-Degree Burn Second-Degree Burn Third-Degree Burn
Thickness
Superficial, partial
thickness
Deep, partial thickness Full-thickness
Appearance
Dry with no blisters Weeping, edematous
blisters
Dry, leathery, and
possibly edematous
Color
Pink White to pink or red,
shiny, wet
subcutaneous layer
after vesicles rupture
White to charred,
eschar
Comfort
Painful, edema,
blanching
Very painful Little or no pain,
edema
Depth
Epidermis only Epidermis, dermis, and
possibly some
subcutaneous tissue
Subcutaneous tissue
and possibly fascia,
muscle, and bone


Diagnostic Test
o Blood chemistry; increased potassium; decreased sodium, albumin, complement fixation,
immunoglobulins
o ABGs; metabolic acidosis
o 24 hr urine collection; decreased creatinine clearance, negative nitrogen balance
o Hematology; increased Hb, HCT; decreased fibrinogen, platelets, WBCs
o Urine chemistry; hematuria, myoglobinuria
Complications
o Hypovolemic shock
o Septicemia
o Acute respiratory failure
o Multiple-organ dysfunction syndrome
Nursing Management
o Ensure patent airway
o Flush chemical from wound and surrounding area with saline solution or water
o Remove clothing
o Establish IV access for hydration and electrolyte replacement
o Begin fluid replacement
o Blot skin dry with clean towels. Do not rub dry.
o Cover burned areas with dry, sterile dressing or clean, dry sheet.
o Diet: high protein, high calorie, with increased fluids (high-calorie, high protein drinks)
o Activity: bed rest if burns are severe
o Treatments: indwelling catheter, postural drainage, chest physiotherapy, incentive spirometry,
and bed cradle
o Elevate affected extremities and provide ROM exercise
o Maintain a warm environment during acute period
o Drug Therapy
o Antibiotics
o Anti-infectives
o Antianxiety
o Antitetanus
o Analgesic
o Colloid
o Diuretic





Emergent Phase Acute Phase Rehabilitation Phase
Fluid Therapy;
Assess fluid needs, insert
indwelling catheter
Fluid Therapy;
Replace fluids
Counsel and teach pat and family
Wound Care;
Start hydrotherapy or cleansing,
debride as neccassary,
administer tetanus toxoid
Wound Care;
Observe for complications,
continue hydrotherapy, and
debridement
Encourage and assist py in
resuming self-care
Pain and Anxiety;
Assess
Early Excision and Garfting;
Provide homograft and,
autografts
Prevent or minimize
contractures and scarring
(surgery, physical therapy, or
splinting
Nutritional Therapy;
Adequate diet
Discuss possible cosmetic or
reconstructive surgury
Physical Therapy;
Begin physical therapy












Glaucoma
o Characterized by visual field loss because of damage to the optic nerve caused by increased
IOP
o The increased IOP results from pathologic changes that prevent normal circulation and
outflow of aqueous humor
o Open-angle glaucoma
o Increased resistance to resistance to aqueous humor drainage, resulting in neuronal
and optic nerve degeneration
o Acute angle-closure glaucoma
o Increased resistance to aqueous humor flow caused by blockage of trabecular
meshwork by the peripheral iris
Common Causes
o Diabetes mellitus
o Previous eye trauma or surgery
o Plateau iris
Clinical Manifestation
o Primary open-angle
o Begins in one eye and progresses to the other eye
o Decreased peripheral vision
o Increased IOP
o Acute angle-closure
o Unilateral
o Acute eye or facial pain
o Halo vision
o Increased IOP
o Nausea and vomiting
Diagnostic Test
o Tonometry; increased IOP
o Gonioscopy; occluded anterior chamber angle
o Opthalmoscopy; edema of the optic disc
Complications
o Blindness
o Infection
Nursing Management
o Dietary restrictions; sodium and fluid
o Drug Therapy
o Topical beta-adrenergic blocker
o Topical adrenergic agonist
o Carbonic anhydrase inhibitor
o Miotic agent
o Sodium restriction
o Surgery
Laser iridectomy; creation of an opening in the iris to allow aqueous humor to
travel to the anterior chamber and trabecular meshwork to decrease intraocular
pressure
Laser gonioplasty; creation of a stromal burn in the peripheral iris to cause iris
contraction and deepen the anterior chamber angle
Trabeculectomy ; a flap of sclera is dissected and a section of trabecular
meshwork is removed to allow outflow of aquous humor
o Avoid such drugs as atropine, anticholinergics, or others with pupil-dilating effects
o Maintain the patients diet and fluid restriction
o Individualize home care instructions
o Be sure to instill eyedrops correctly
o Avoid rubbing the eyes
o Use an eye shield or patch during sleep
o Apply wet and cold compresses, as prescribed
o Avoid coughing, sneezing, lifting, constipation, squeezing eyes shut, and fast head
movements.
o Avoid smoking
o Wear protective glasses or gobbles while participating in sports or swimming
o Monitor the eyes for redness, discharge, watering, blurred or cloudy vision, halos,
flashes of light, and floaters

Retinal Detachment
o Separation of the sensory layers of the retina from the underlying retinal pigment epithelium
o Vitreous body traction causes retinal tears or holes
o Vitreous fluid leaks through holes or hears behind the retina
o Retinal separation occurs
Common Causes
o Aging
o Diabetic neovascularization
o Trauma
o Intraocular surgery
Complications
o Blindness
o Infections
Clinical Manifestations
o Floating spots
o Recurrent flashes of light (photopsia)
o With progression of detachment, painless vision loss may be described as a veil, curtain, or
cobweb that eliminates part of the visual field.
Diagnostic Test
o Ophthalmoscopy; grey or opaque retina
o Indirect ophthalmoscopy; retinal tear or detachment
o Ultrasound; retinal tear or detachment in the presence of a cataract
Medical Management
o Activity
o Complete bed rest with the retinal hole or tear at the lowest point of the eye
o Restrict eye movement until surgical reattachment
o Provide preoperative care
o Maintain bed rest with the retinal hole or tear at the lowest position of the eye
o Apply an eye patch
o Explain the procedure and what to expect postoperatively
o Administer preoperative antibiotics
o Wash the face with no-tear shampoo
o Administer cycloplegic-mydriatic eyedrops as ordered
o Provide postoperative care
o Position the pt as ordered
o Tell the pt to avoid activites that increase IO, such as coughing, sneezing, vomiting,
lifting, straining during bowel movements, bending from the waist, and rapidly moving
the head
o Administer antiemetics, as indicated
o Protect the eye with a shield or glasses
o Apply cold compresses as ordered
o Administer analgesics as needed
o Administer cycloplegic and steroid-antibiotic eyedrops as ordered
o Individualize home care instruction
o Instill eyedrops, as prescribed
o Notify the physician if experiencing floaters, flashes of light, blurred vision, or pain
unrelieved by analgesics
o Report fever, yellow or green eye discharge, increased redness or puffiness of the eye,
or reduced vision
o Perform dressing changes
o Wear an eye shield at night
o Wear prescribed eye goggles while participating in contact spots
o Follow activity restrictions and head positioning
Surgical Intervention
o Cryothermy
o Laser therapy
o Sclera bucking procedure
o Is applied around the retinal tear, producing a chorioretinal adhesion that seals the
break so that liquid vitreous can no longer pass through the subretinal space