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Nursing patients with sensory system problems (eyes, ears, nose, and throat) 

Nursing patients with sensory system problems (eyes, ears, nose, and throat)

Chapter:
Nursing patients with sensory system problems (eyes, ears, nose, and throat)
DOI:
10.1093/med/9780199231355.003.0014
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  • Eye

  • Nursing assessment of patients with eye problems [link]

  • Nursing problems of the eye [link]

  • Eye tests and investigations [link]

  • Eyelid and corneal disorders and eye infections [link]

  • Other common eye problems [link]

  • Nursing care of patients with visual impairment [link]

  • Nursing care of patients undergoing eye surgery [link]

  • Postoperative nursing care of eye patients [link]

  • Education for patients with eye problems [link]

  • Discharge and continuing care for patients with eye problems [link]

  • Ear

  • Nursing assessment of patients with ear problems [link]

  • Ear tests and investigations [link]

  • External ear conditions [link]

  • Middle and inner ear conditions [link]

  • Patients undergoing ear surgery [link]

  • Patients with hearing impairment [link]

  • Communicating with hearing-impaired patients [link]

  • Nursing care of patients with ear problems [link]

  • Education for patients with ear problems [link]

  • Discharge and continuing care for patients with ear problems [link]

  • Nose and throat

  • Nursing assessment of patients with nose and throat problems [link]

  • Nursing patients with nose and throat problems [link]

  • Nose and throat tests and investigations [link]

  • Conditions of the nose [link]

  • Nursing care of patients undergoing nose surgery [link]

  • Conditions of the throat [link]

  • Nursing care of patients undergoing throat surgery [link]

  • Communicating with patients following laryngectomy [link]

  • Nursing care of tracheostomy patients [link]

  • Education for patients with nose and throat problems [link]

  • Discharge and continuing care for patients with nose and throat problems [link]

  • Common drugs used for ear conditions [link]

  • Common drugs used for eye conditions [link]

  • Common drugs used for nose, throat, and mouth conditions [link]

Nursing assessment of patients with eye problems

In addition to a general nursing assessment ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 3, Individualizing nursing care practice, pp.[link][link]) perform the following procedures.

Observe the patient

  • Infection of the eye: redness, watering, discharge (note amount and consistency), crusting, swelling, abscess, and styes. Is infection unilateral or bilateral? Does the patient rub their eyes?

  • Exophthalmos: protrusion of the eyeballs, most commonly associated with thyroid eye disease. Also consider eyelids, ptosis, ulcers, ectropions, blepharitis.

  • Pupils should be round, central, of equal size, and respond equally to light. Observe for abnormal pupil shape and size.

  • Squint: eyes are not correctly aligned with each other; in children it is of particular concern because they may not develop normal vision (amblyopia or ‘lazy eye’).

  • Signs of injury: penetrating wounds, bruising around eye, or corneal abrasion.

  • See Fig. 14.1 for diagram of the eye.

Ask the patient about

Nursing history

  • Ability to manage self-care and activities of daily living

  • Coping strategies

  • Social situation (any dependants at home or anyone to care for them or is the patient isolated)

  • Past and present nursing problems

  • Psychological and spiritual assessment

  • Fears and anxiety about the eye condition and what they understand about it, and possible care and treatment

Medical history

  • Renal disease and hypertension (retinal vein occlusion may occur)

  • Diabetes (diabetic retinopathy)

  • Rheumatoid arthritis (keratoconjunctivitis—dry eye and scleritis)

  • Visual disturbances, diplopia, and optic neuritis in multiple sclerosis

  • Use of specific drugs (e.g. anticoagulants, antihypertensive, recreational drugs)

Specific eye history

  • Prescription glasses, reading, distance, both, varifocals, bifocals

  • Contact lenses, artificial eye, methods of removal, cleaning, and storage

  • Whether registered as visually impaired or severe visual impairment

  • Whether under the care of an ophthalmologist

Present symptoms

  • Visual disturbances including blurred or distorted vision, dark spots in the visual field, flashing light, floaters, rainbow colours or halos around bright lights

  • Photophobia

  • Headaches, irritation, discharge, pain, inflammation

  • Changes in vision

Family history

  • Glaucoma

  • Visual impairment and causes

  • Diabetes

  • Coronary heart disease

  • Hypertension

Test and measure

  • Blood pressure—high blood pressure increases risk of a variety of retinal problems especially in patients with diabetes.

  • Urine—protein may indicate renal disease and glucose or ketones may indicate diabetes.

  • Pupil reaction—asymmetry of the pupils may indicate serious disease.

    • Causes of an abnormally constricted pupil include drugs, nerve damage (Horner’s syndrome), and previous iritis (inflammation of the iris which can lead to it being stuck down onto the lens).

    • Causes of an abnormally dilated pupil include drugs, nerve damage (third nerve palsy which is serious or Adies pupil which isn’t), trauma, and glaucoma.

Nursing problems of the eye

Impaired vision

The degree of impaired vision varies—blindness, blurring, patchy or cloudy vision, distortion of vision.

Photophobia

This is painful sensitivity to light.

Eye pain

Pain is often severe if it is due to corneal abrasions, foreign bodies, scleritis, or acute glaucoma. It is less severe in conjunctivitis, keratoconjunctivitis, and optic neuritis. Eye pain may also be due to referred pain, trigeminal neuralgia, shingles, migraine, and tension headaches. It may also occur postoperatively or after laser treatment.

Dry eyes

Dryness causes irritation and redness and is due to reduced secretion of tears, evaporation of tears, or mucin deficiency in tears.

Eye discharge

Discharge may be watering or purulent due to infection. It may result in sticking of eyelids, especially on waking.

Anxiety

This may be due to concerns about possible deterioration in sight leading to blindness or due to fears that treatment and tests may be painful.

Social isolation

This may result from lack of confidence with other people (inability to recognize familiar faces) and difficulty undertaking activities (problems with driving, getting about, hobbies, e.g. writing, sewing). Some eye problems can be visible to others and this can lead to inappropriate attention to the patient causing discomfort and embarrassment.

Lack of appropriate visual aids

These include ill-fitting spectacles, difficulty inserting or removing eye prosthesis, or contact lenses.

Common terms in ophthalmology

  • Conjunctivitis: inflammation of the conjunctiva (the delicate transparent membrane that lines the eyelids and the eyeball)

  • Diplopia: double vision

  • Entropion: inversion of the eyelid—the lashes are in contact with the eyeball

  • Enucleation: removal of the eye

  • Exophthalmos: protrusion of the eyeball

  • Nystagmus: involuntary rhythmic movement of the eyeball

  • Papilloedema: unilateral or bilateral oedema of the optic disc due to raised intracranial pressure

  • Photophobia: painful sensitivity to light

  • Scleritis: inflammation of the sclera (the white of the eye)

Eye tests and investigations

Visual acuity

Visual acuity is tested with most recent glasses on (if worn) using either Snellen’s test board or LogMAR visual acuity (with distance glasses, bifocal, varifocal, or contact lens). Near vision can be tested by reading a book or newspaper (with reading glasses). Record the smallest type or object read or named.

Ophthalmoscopy

This is mainly used to look at the retina. It may detect retinal haemorrhages, or exudates (e.g. in diabetic retinopathy), retinal detachment, cupped discs (indication of glaucoma), abnormal vitreous and blood, loose floaters, or red reflex. Additionally it can be useful to spot opacity of lenses (cataract) or abnormal pupils. When viewing the retina, it helps to darken the room and use appropriate prescribed mydriatic drops to dilate the pupil. Before administering these drops patients should be warned that their vision will be blurred and that they should not drive until this wears off (commonly a few hours but occasionally until the next day).

Examination with slit lamp

This provides a slit of light of variable thickness and angulation that is viewed through a binocular microscope that gives a magnified view of the structures of the front of the eye. Additional hand-held lenses are required to view the back of the eye (e.g. retina, optic disc).

Tonometry

This is used to check intraocular pressure (IOP). Use either Goldmann’s tomometry or Tono-Pen®. It is essential that the patient keeps eye still and open. The Tono-Pen or the Perkins Tonometer is good to use to check IOP for bed or wheelchair bound patients. All these instruments should only be used after a drop of topical anesthetic has been administered.

Fundus fluorescein angiography

Dye is injected into veins to highlight retinal blood vessels to detect leakage and dilation. Take precautions in case of anaphylactic shock. Observe for 30 minutes post-procedure. Skin and urine turn yellow.

Fundus photography

This is used to record the retinal appearance.

Visual field test (‘perimetry’)

Visual acuity tests evaluate only a patient’s very best central vision. Visual field tests assess the peripheral vision as well. The final result is a map of the quality of the whole of the patient’s vision.

CT scan

Computed tomography (CT) of the head is used to identify tumours affecting the occipital lobe and optic nerve.

X-rays

X-rays are used to detect associated problems (e.g. chest x-ray in ocular inflammation to look for sarcoidosis or TB).

Ultrasound scan

These scans are used to measure structures inside the eye (e.g. before cataract surgery) and to examine the eye when you cannot see the back (e.g. haemorrhage or cataract).

Laboratory tests

FBC, blood glucose, U&E and a lipid profile may be indicated.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 39, Common laboratory tests and their interpretation, p.[link].

Eyelid and corneal disorders and eye infections

Styes (hordeolum)

External styes:

due to infection of lash follicle in lid margin. Treatment is with lid hygiene and warm compresses, and commonly topical antibiotics.

Internal styes:

less common, due to infected meibomian gland. May produce cysts that point and discharge inwards onto conjunctiva. Treatment is with lid hygiene, warm compresses, and commonly topical antibiotics.

Chalazion (meibomian cyst)

This is a hard and pip-like lump that often follows a staphylococcal infection. It usually resolves on its own. Treatment includes lid hygiene and lid massage using warm flannel. Persistent cases may require incision and curettage of chalazion under local anaesthetic.

Basal cell carcinoma

This is the commonest malignancy of the eyelid. It may start as a pearly nodule that becomes ulcerated with time. Treatment includes excision, curettage, cryotherapy, or radiotherapy.

Blepharitis

This is an extremely common chronic infection of the eyelid margins. It causes red, itchy, crusted, and scaly lids. It is sometimes associated with conjunctivitis. Treatment includes removing crusts and scales by frequent soaking with compresses of sodium bicarbonate. Antibiotics and also steroid drops may be required if the condition persists.

Lacrimal duct problems

Dacryocystitis is inflammation of the lacrimal sac causing redness, swelling, and watering of eye due to a blocked tear duct. Pus may regurgitate from the tear ducts. It may spread to surrounding tissue and lead to systemic infection. A swab of discharge should be taken before antibiotics are prescribed.

Orbital cellulitis

This may follow sinusitis or periorbital injury. Patients present with fever, eyelid swelling, pain, general malaise, and discharge and congestion of the eye. Blood cultures should be taken before IV antibiotics. A CT scan and ENT opinion regarding involvement with paranasal sinuses may be required. Complications include meningitis, retinal vein occlusion, optic nerve compression, blindness, and cavernous sinus thrombosis. Check patient’s temperature. More common and less serious is ‘preseptal cellulitis’. This is infection of the lid that has not spread back into the orbit. Although the lid may appear very swollen, the other features of orbital cellulitis are present. In adults it is normally treated with oral antibiotics as an outpatient; in children, however, it should be managed as for orbital cellulitis.

Conjunctivitis

This may be due to allergy, bacterial infection (e.g. Staphylococcus, pneumococci), viral infections (e.g. adenovirus), or chlamydia. Eyes are often gritty, sticky, itchy, and sore, with discharge and mild photophobia but no change in vision. Conjunctivitis is usually bilateral. Remove discharge with moist cotton wool balls; avoid cosmetics and eye lotions. Scrupulous handwashing is required. Antibiotic eye drops (e.g. chloramphenicol) are usually prescribed for bacterial and viral infections (to prevent secondary bacterial infection). If conjunctivitis is of particular concern or if it persists, an eye swab may be taken. In allergic conjunctivitis a range of anti-allergy drops are available; in severe cases topical steroids or antihistamine drops may be prescribed by an ophthalmologist. Advise patients not to share towels at home to minimize risk of cross infection.

Ectropion

Ectropion is a turning-out of the lower eyelid. This condition can cause eye irritation and watering. Surgery may correct the deformity.

Entropion

Entropion is a turning-in of the lower eyelid. This condition can cause eye irritation and watering. The in-turned eyelashes may irritate the cornea. Taping the lower eyelid to the cheek can give relief temporarily; surgery may be required.

Other common eye problems

Macular degeneration

This is the leading cause of blindness in patients >65 years. It affects both eyes with deterioration in central vision (blurring, distortion, dark spots, problems in bright sunlight, and difficulty adapting between dark to light) and causes problems with reading, writing, and recognizing faces. Risk factors include age, sunlight, family history, smoking, and diet. Prevention is aimed at reducing risks. Advise patients to use magnifying devices, large print, and talking equipment (books, clocks, etc.). Patients should consider registering as ‘severely sight impaired’ (blind) or ‘sight impaired’ (partially sighted). Treatment involves laser photocoagulation. Acute macular degeneration (AMD) is treated by photocoagulation. Some centres treat wet AMD with photodynamic therapy and (most recently approved by NICE) by Lucentis injection.

Cataract

Cataract refers to lens opacity. It is usually progressive and patients have reduced ability to focus and perceive colour, blurring or loss of vision, halos around objects, and increased glare. Causes include congenital infection (rubella), familial, senile, traumatic, radiation exposure, and drug induced, e.g. long-term steroids. Diabetes may give similar symptoms and should be excluded. Treatment includes extraction combined with plastic lens implant, normally as day case with local anaesthesia. The patient must be able to lie still for 30 minutes. The affected eye is dilated. Postoperative antibiotics and steroid eye drops are given 4 times per day, commonly for 2–4 weeks. The first eye dressing is worn 24 hours postoperatively, and may be removed by the patient. For the first few weeks the patient should avoid lifting, bending, smoky atmosphere, make-up, hairspray, and swimming. An eye shield should be worn at night for 2 weeks to prevent inadvertent rubbing.

Glaucoma

Raised intraocular pressure causes damage to the optic nerve leading to loss of vision. Glaucoma is usually chronic (primary open angle glaucoma or POAG). The pressure is not so high as to cause pain, but it can cause considerable damage to the optic nerve. However, because it affects the peripheral vision first, the patient may be unaware. It is usually first noticed by an optician at a routine test. Risks include increased age, African origin, family history, diabetes mellitus, thyroid eye disease, and short-sightedness. Medical treatment includes lowering the pressure with topical prostaglandin agonists and/or beta-blockers (e.g. timolol). Surgery (trabeculectomy) may be necessary in some cases. Patients who are >40 or who have a family history of glaucoma should have an annual eye check for glaucoma. For patients being treated for glaucoma, it is very important to stress the importance of drop concordance. Assess and teach drop instillation techniques.

Much less common is acute ‘angle closure’ glaucoma. This is an ophthalmic emergency in which the intraocular pressure is extremely high causing the patient substantial pain. The eye is red and hard, the cornea is cloudy, and the pupil is unreactive. This requires urgent treatment with drops (including pilocarpine) and intravenous medication (commonly acetazolamide). Once things have settled, the definitive treatment is with laser ‘peripheral iridotomy’ which usually prevents recurrence.

Retinal detachment

Initially, patients see a shadow across the vision of one eye. They may see bright flashes or floaters beforehand, but there is no pain. Risks include middle age, short-sightedness, and previous detachment. At a very early stage this may be treated by laser or cryotherapy under local anaesthetic. Most cases, however, require surgery by ‘vitrectomy’ (i.e. repair from the inside) or by ‘Cryo-buckle’ (i.e. repair from the outside). In vitrectomy the vitreous is removed and either a gas or silicone oil is used to ‘inflate’ the eye, which pushes the retina back in place. This operation is done mostly under general anaesthesia but can be done under local anaesthesia. The extent to which the patient is able to see afterwards depends partly on whether the retinal detachment extended to affect the central vision. If so, the ability to see fine detail may not return. Preoperative education is important to alleviate anxiety. Patients are given strict instruction following vitrectomies where a gas bubble is injected. The patient is advised to inform the anaesthetist if admitted to hospital for another operation within 6 weeks post-vitrectomy. Patients should not travel by plane while gas is in the eye. The gas bubble takes an average of 6 weeks before it is absorbed. Advice on resuming normal activities should be sought from the surgeon and supporting team.

Diabetic retinopathy

Background diabetic retinopathy

—blocked, dilated, or leaky retinal capillaries become fragile and haemorrhage; usually asymptomatic and not sight threatening

Proliferative diabetic retinopathy

—damaged blood vessels reduce blood supply to retina, which leads to new fragile blood vessels developing, scarring, and detached retina

Diabetic maculopathy

– ischaemia and/or leakage of fluid reduce the function of the macula affecting central vision

Appropriate treatment of the underlying diabetes is required. Photocoagulation by laser can be used to treat both maculopathy and proliferative retinopathy. Patients following retinal surgery are also advised to keep their heads in a certain position postoperatively for 5–10 days to enable the internal tamponade (gas or silicone oil) to work on affected part of the retina to keep the retina flat.

Nursing care of patients with visual impairment

Visually impaired people may lack confidence out of their normal environment. The nurse should aim to minimize stress of an unfamiliar hospital setting. Patients may have fluctuating vision or difficulty adjusting to sudden changes in light. Remember not all people with visual impairment are the same.

Communication

  • Use the patient’s name as an introduction; introduce yourself by name and role.

  • Talk to the person, not their companion or guide.

  • Use the patient’s name or touch them so they are aware of being addressed.

  • Give them time to speak and listen to them.

  • Recognize that visually impaired people may be more alert to tone of voice.

  • Provide ‘talking’ information, e.g. ward information, visiting information.

  • Let the patient know when you are leaving.

Guiding

  • Introduce yourself and ask if assistance is required—verbal guiding or by touch.

  • Allow person to hold your arm just above the elbow.

  • Be aware of obstacles that are at head height.

  • Walk at person’s pace and describe what they are approaching (e.g. doors, level change, narrow passage, flooring).

  • For stairs, indicate whether going up or down and guide to handrail. Warn patient when top or bottom is approaching and reached.

  • For seating, place guiding hand onto chair back or seat—patient can do the rest.

  • Never distract a patient’s guide dog or feed a working dog.

Ward orientation

  • Describe bed area and how items work—radio, headphones, call bell.

  • Show location of bed, locker, toilets, and internal layout.

  • Offer to guide to facilities.

  • Describe meal times—make patient aware of meal times and describe how food is laid out, e.g. use clock (peas at 10 o’clock etc.). Ask whether help is needed, e.g. with choosing menu, feeding.

  • Replace objects in the exact place they were found.

Nursing care of patients undergoing eye surgery

Pre- and postoperative education

Preoperative education is important to alleviate anxiety.

Preoperative nursing care

Approximately 80% of eye surgery is performed under local anaesthetic as day cases. An individualized plan should be developed.

  • Assess suitability for day case surgery according to local criteria, e.g. type of surgery, living alone, support, access to telephone, mobility, ability to return for postoperative visit, ability to self-care.

  • Obtain a nursing history and assessment.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Nursing assessment of patients with eye problems, p.[link].

  • Orient patient to environment.

  • Gain cooperation during surgery. Patient must be able to lie flat and keep still. Carefully explain procedures; what they will see, hear, and feel during the operation; how long it will take. Retain hearing aids for communication.

  • Advise patients to wash hair preoperatively as this may be restricted after.

  • Teach postoperative techniques, e.g. instilling eye drops.

  • Prepare eye area according to local policy. This may or may not include conjunctival swabs for culture and sensitivity, instilling prescribed eye drops (e.g. antibiotics; mydriatic drops to dilate pupils; local anaesthetic drops; and miotic drops to constrict pupils), and marking eye to be operated on.

  • Encourage patient to be mobile pre- and postoperatively, unless there are any contraindications, e.g. bed rest in retinal surgery.

  • Check that the consent form has been signed and ask if there are further questions about risk and consequences of the surgery.

  • Discuss the patient’s anxieties (e.g. pain, loss of sight, return home) and plan care appropriately or make referrals for further support, e.g. social worker.

  • Follow principles for preoperative preparation, if general anaesthetic is being used.

  • Highlight any relevant problems to the medical team.

Perioperative care

  • If possible the patient may walk in and walk out of theatre.

  • The patient’s head must be correctly positioned and supported to prevent unnecessary movement.

  • A nurse should sit and hold the patient’s hand to provide support and observe patient’s condition, e.g. skin colour, sweating, pulse rate, and chest movements.

  • For patients with local anaesthetic, agree a sign (e.g. squeeze nurse’s hand) to indicate a concern (e.g. impending sneeze, need to speak).

  • Provide explanations during surgery to help reduce anxiety, prevent disorientation, and keep patient informed of what is happening.

Postoperative nursing care of eye patients

Day case surgery

Most patients have day case surgery, usually under local anaesthetic, and can begin mobilizing to prepare for discharge home shortly after surgery is finished. Ensure patients have information and medication including eye drops prior to discharge.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Discharge and continuing care for patients with eye problems, p.[link].

Inpatients

Most inpatients will have had a general anaesthetic, more complex surgery, or do not have the support systems at home to enable them to have day surgery. Nursing care is determined by the type of surgery but commonly will include:

  • Resting in bed for the first day but allowed up for toilet. Should be gradually mobilized to prepare for discharge from complex retinal surgery.

  • Preferred position when lying is for the operated eye to be uppermost to relieve pressure; for some operations the patient must lie on their stomach.

  • Assessing the patient’s pain and administering prescribed analgesia.

  • Eating and drinking may be resumed an hour after return if there is no nausea or other contraindications.

  • If eyes are covered, guiding patients to bathroom and around ward; and helping to locate belongings and perform aspects of care.

  • Normally the dressing and eye shield, if used, is left for 24 hours.

  • Providing explanations about surgery and what happened.

  • Preparing for discharge and providing information.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Discharge and continuing care for patients with eye problems, p.[link].

Eye dressing and eye check

  • Inspect dressing pad for blood or discharge.

  • Ask about pain.

  • Compare the eyes. Observe the operated eye for swelling, discharge, stickiness, bruising, and redness of the eyelid; redness of the conjunctiva for subconjunctival haemorrhage; the cornea for clarity or abrasions; the pupils for abnormality of shape and size, and reaction to light; and observe the suture line. Record findings.

  • Bathe the eye according to local policy, e.g. with gauze swabs and sterile normal saline from inner to outer eye margins, to remove discharge, blood, and any stickiness.

  • Insert eye drops as prescribed ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Instillation of eye drops, p.[link]). Replace dressing and eye shield if required or dark/shaded glasses.

  • Discuss registering as partially blind/fully blind.

Education for patients with eye problems

Patient with existing eye problems

  • Use a model of the eye to explain patient’s condition and planned effects of treatment and surgery.

  • Explain the importance of handwashing and other actions to prevent infection before, during, and after eye care.

  • Teach patient and carer how to instill eye drops; supervised practice is preferable. Give large-print instructions.

  • Teach eye cleaning when eyes are sticky. Use cooled boiled water; make up enough for the day and keep in refrigerator. Use gauze or cotton wool balls and wipe from inner to outer eye—one swab per wipe.

  • Give information about medication.

  • Explain ‘what to do’ and ‘what not to do’ to protect the eye and prevent complications, e.g. haemorrhage, infection. This will vary depending on the condition. Instruct patients to avoid bending down, lifting heavy weights, constipation, activities that may induce coughing or sneezing, and washing hair, unless backwash is used. Instruct patients to avoid smoky atmosphere, to be cautious with make-up and hair spray, and not to rub eyes.

  • Encourage patients to ask questions and express fears about care and treatment and longer-term prognosis.

  • Suggest practical help for patient to improve vision—large-print books, prescribed magnifying glasses, better illumination.

  • Explain about eye dressing/eye protection: when it will be removed, what the eye will look like, and whether dressing will be replaced.

Preventive education

This is aimed at reducing the risk of eye problems developing and/or deteriorating.

  • Educate on early detection of eye disease by regular eye tests which include slit lamp examination/ophthalmoscopy (to examine the optic disc), tonometry (to measure the intraocular pressure), and perimetry (to examine the field of vision) at least every 2 years but more frequently if deterioration is noted.

  • Ensure leaflets on a variety of eye diseases and their prevention are available in a range of languages.

  • Advise patient to:

    • Wear sun glasses and brimmed hat when in excessive sunlight to prevent cell damage and subsequent macular degeneration.

    • Eat a healthy diet rich in fruit and green vegetables. Limit saturated fats and cholesterol to reduce risk of age-related macular degeneration.

    • Limit alcohol intake to recommended daily level.

    • Stop smoking.

    • Keep blood pressure down.

  • Advise diabetics that glycaemia and blood pressure control are important, including managing insulin regimen, adhering to diet, and exercising with modifications, if necessary. Advise patients to participate in retinal screening programmes.

Instillation of eye drops

  • Wash and dry hands and ensure this is done between treating each eye if both eyes are involved.

  • Collect equipment (correct drug, prescription sheet, sterile swabs).

  • Identify patient, explain procedure and effect of eye drops, and gain consent.

  • Cross-check drug with prescription sheet, patient, and identify correct eye.

  • Wash and dry hands.

  • Ask the patient to look up and gently evert the lower lid and put a drop into the lower conjunctival fornix.

  • Putting gentle pressure over the lacrimal sac (just below the medial aspect of the eye) improves absorption to the eye and can reduce systemic absorption

  • Ask the patient to close their eyes and wipe away any excess.

  • Wash and dry hands.

  • Record that the drug has been given.

  • Wait 5–10 minutes before further drugs are given in the same eye.

  • Make sure that the patient is happy doing this for themselves.

Discharge and continuing care for patients with eye problems

  • Follow the discharge process.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 38, Discharge planning, p.[link].

  • Check patient and carer understand eye care requirements.

  • Check patient knows how to instill eye drops properly.

  • Check patient has medication and understands use, effects of non-concordance, possible side effects, and where to obtain further prescriptions.

  • Explain when to resume driving. This varies with type of condition or operation. Seek ophthalmologist’s guidance—normally patient must be able to read at level 6/9 on the Snellen Chart ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Appendices, Eye Chart, p.[link]). May be able to drive with only one functioning eye but insurance company should be informed.

  • Give phone number for hospital in case of problems.

  • Air travel may be restricted for a period in certain conditions, e.g. following complicated retinal surgery.

  • Advise patient to rest if tired—the convalescence period will vary depending on individual and condition. Seek advice on resuming normal activities (e.g. driving) from the surgeon and supporting team.

  • Arrange for patient to be visited by specialist nurse or return for dressing check and removal, or give patient information on how to remove own dressing.

  • Arrange outpatient appointment with ophthalmologist and for sight test 2–4 weeks postoperatively for cataract patients.

  • Encourage patients to have eye tests at least every 2 years and explain how this might save sight.

  • Provide list of ophthalmic opticians who make domiciliary visits for housebound patients.

  • Provide information on who is exempt from eye test charges.

  • Ensure patient has details of Royal National Institute for the Blind, social service, and local and national voluntary organizations to assist in maximizing remaining vision.

  • Provide information on how to register as partially sighted or blind if sight loss is serious.

Further information

Royal National Institute for the Blind (RNIB): www.rnib.org.uk

International Glaucoma Association (IGA): www.iga.org.uk

Macular Disease Society: www.maculardisease.org

Driver and Vehicle Licensing Agency (DVLA): www.dvla.gov.uk

Diabetes UK: www.diabetes.org.uk

Nursing assessment of patients with ear problems

In addition to a general nursing assessment ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 3, Individualizing nursing care practice, pp.[link][link]) perform the following procedures.

Observe the patient

  • Signs of trauma to the ear, e.g. skin or cartilage damage to the pinna. Is there any bleeding or discharge due to injury to the external ear canal or eardrum, or from a skull base fracture?

  • Discharge from the ear canal that may indicate bacterial or fungal infection.

  • Swelling or deformity around the ear due to subperichondrial haematoma, mastoiditis, or furunculosis (infected hair follicle).

  • Nystagmus, imbalance, unsteadiness, nausea, vomiting, and sweating—may indicate problems with the inner ear.

  • Facial nerve palsy—may be due to acoustic neuroma, acute or chronic otitis media, herpes zoster, or Bell’s palsy.

  • Use of hearing aid or problems with communication—may indicate degree of hearing impairment.

  • Evidence of recent surgery.

  • See Fig. 14.2 for a diagram of the ear.

Ask the patient about

Nursing history

  • Ability to manage self-care and activities of daily living

  • Coping strategies, such as how they manage communication if there is hearing impairment (e.g. lip reading, sign language)

  • Social situation (any dependants at home or anyone to care for them)

  • Past and present nursing problems

  • Psychological and spiritual assessment

  • Fears and anxiety about the ear condition and prognosis, what they understand about it, and the care and treatment planned

Potential nursing problems

  • Hearing impairment (gradual or sudden onset)

  • Dizziness or loss of balance

  • Episodes of nausea, vomiting, pain, or headaches

  • Communication problems (inability to follow conversations, saying pardon frequently, turning up the radio and TV, people appear to mumble)

  • Sleep problems

Specific ear history

  • Use of hearing aids

  • Hearing tests

  • Previous ear surgery or procedures, e.g. removal of wax

  • Frequent swimmer

  • Recent ear infections or trauma

  • Foreign bodies

  • Exposure to loud noises

Past medical history

  • Infectious diseases, e.g. herpes zoster, meningitis, measles—may result in hearing impairment

  • Drugs—ototoxic drugs may cause deafness

  • Family history of ear problems

  • Trauma

  • Past surgery

Ear tests and investigations

Examination of the ear

An auroscope is used to examine the external canal and eardrum (See Fig. 14.3). Use the largest speculum that will fit comfortably in the entrance of the canal; ensure batteries are working. Gently pull the pinna upwards and backwards to straighten the canal. It will be possible to see wax, debris, foreign bodies, and the eardrum (unless wax is impacted against it).

Fig. 14.3 Examination of the ear with an auroscope. (a) Straighten the ear canal as much as possible and select the largest speculum that fits comfortably in the patient’s ear. (b) If the patient is uncooperative or restless hold the handle upwards. (c) Position of the speculum in the ear. (d) Diagram showing the ear drum as seen through the auroscope.

Fig. 14.3
Examination of the ear with an auroscope. (a) Straighten the ear canal as much as possible and select the largest speculum that fits comfortably in the patient’s ear. (b) If the patient is uncooperative or restless hold the handle upwards. (c) Position of the speculum in the ear. (d) Diagram showing the ear drum as seen through the auroscope.

Hearing tests

Voice tests

These gauge the patient’s ability to hear speech. One ear is occluded with finger; words or numbers are whispered in the other ear and the patient repeats.

Tuning fork tests

These are used to distinguish between conductive and sensorineural deafness.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Types of hearing loss, p.[link].

  • Rinne’s test: This test compares the patient’s ability to hear a tone conducted by air and bone. Patients are asked whether a vibrating fork is louder when placed on the mastoid process (bone-conduction) or when placed in line with the external canal (air-conduction). In normal hearing the tuning fork is heard more clearly when held in line with the external canal (i.e. the sound is louder by air conduction and this is called a Rinne positive test). In conductive hearing loss, the tuning fork is heard more clearly when placed on the mastoid process (i.e. the sound is louder by bone conduction and this is called a Rinne negative test).

  • Weber’s test: This test compares bone conduction in both ears to determine whether a unilateral hearing loss is conductive or sensorineural. A vibrating fork is placed in the centre of the forehead.

    • Patients who perceive the sound in the midline have normal hearing.

    • Patients who perceive the sound better in the poorer ear have conductive loss.

    • Patients who perceive the sound better in the better ear have sensorineural loss.

Audiometry

  • Pure tone audiometry: assesses hearing loss by air and bone conduction. Pure tone signals are fed to the patient either by a vibrator attached to the mastoid process (bone conduction) or via ear phones (air conduction). Used for a general assessment of hearing.

  • Speech audiometry: assesses the patient’s ability to understand speech. A tape of words at varying intensities is played; the percentage of correct words repeated is plotted against a speech audiogram.

  • Tympanometry (impedance test): tests for middle ear compliance. The pressure in the external canal is altered; at each setting, sound is passed to the ear and the reflected sound energy is measured.

  • Audiometry electric response: surface-recording electrodes are placed on the head and used to study the response of different auditory pathways to sound.

External ear conditions

Trauma

Foreign body

causes pain, discomfort, hearing loss, and infection if left. Remove with instruments if the foreign body is superficial and the patient is cooperative. If the patient is uncooperative, there is a danger of eardrum damage and removal under general anaesthesia may be needed.

Blunt trauma

to the pinna may cause bleeding and haematoma. It must be aspirated under local anaesthesia and dressed with firm pressure to prevent deformity. Antibiotics are given to prevent infection.

Perforated eardrum

can result from sharp object, fracture to base of skull, blast injury, or changes in barometric pressure (e.g. in scuba diving). Patient has pain, conductive deafness, and sometimes bleeding. Do not attempt to clean ear and keep dry. Antibiotics are given to prevent infection. Referral to ENT specialist is usual.

Infections and other non traumatic conditions

Impacted ear wax

against the eardrum causes hearing loss. It develops due to difficulty in shedding debris and wax in people who have narrow ear canals, who wear earplugs, or who have hearing aid moulds. Treatment includes irrigation or microsuction. Advise on prevention.

Otitis externa

is a bacterial or fungal infection due to scratching (e.g. in eczema) or exposure to water (swimmer’s ear). It results in pain, discharge, and swelling of the ear canal and often the surrounding lymph nodes. Treatment includes aural toilet to remove debris, antibiotic and steroid ear drops, or antifungal drops and pain relief. Advise on keeping ears dry. Referral to ENT specialist may be required.

Furunculosis

is an infection of a hair follicle in the ear canal. It causes severe pain. Treatment includes pain relief, topical antibiotics and steroid drops, and oral antibiotics if there is surrounding inflammation. Aural toilet is required if there is a discharge of pus. Test urine for sugar to detect diabetes mellitus.

Herpes zoster

(Ramsay-Hunt syndrome): vesicles appear in the external canal and around the ear. Pain, deafness, vertigo, and 7th nerve palsy may occur. A history of chickenpox or previous shingles is usual. Pain relief is essential. Antivirals (e.g. acyclovir) and steroids may be helpful for palsy.

Nursing care

  • Focuses on individual needs and identified problems.

    • Pain relief

    • Support and presence during procedures

    • Explanations of condition, care, procedures, treatment, and next steps

    • Information on further prevention

  • Use aseptic techniques for dressings and make arrangements for removal/change of dressings and appointments for follow-up.

  • Ensure patient understands medications and can insert drops.

Middle and inner ear conditions

Acute otitis media

This is common in children due to bacterial or viral infections. Patients present with earache, conductive deafness, pyrexia, and general malaise. Spontaneous perforation of the eardrum may occur resulting in pain relief and discharge of pus. Management includes pain relief (e.g. paracetamol); antibiotics if there is no improvement after 2–3 days; and nursing care to monitor and reduce fever, including fluids and keeping the patient comfortable. Mastoiditis is a complication.

Glue ear

Otitis media with effusion may follow acute episode of otitis media due to inadequate drainage via the eustachian tube. It results in deafness and speech and language problems. Long-term antibiotics and mucolytics may help. Surgery includes insertion of grommets with or without adenoidectomy.

Mastoiditis

Infection from the middle ear extends into the mastoid air cells resulting in pyrexia, tenderness and swelling over the mastoid, discharge, and hearing loss. Treatment is usually IV antibiotics. Nursing care depends on symptoms and includes pain relief, reduction of fever, aural toilet, encouraging fluids, and keeping the patient comfortable. Cranial nerve palsy, meningitis, and brain abscesses are complications.

Tinnitus

This refers to any sound heard in the ear not from an external source normally described as ringing, buzzing, and whistling. The cause is often unknown but may be linked to exposure to loud noises, hearing loss, head injuries, Ménière’s disease, raised blood pressure, or drugs. In severe cases it interferes with daily life and causes depression. It is always investigated by an ENT surgeon to ensure that there is no sinister cause such as an acoustic neuroma. Reassurance and psychological support is important. Suggest support group and contacting help lines.

Ménières disease

This is a relatively rare inner ear disorder presenting with episodes of vertigo, fluctuating hearing loss and tinnitus, and a sense of fullness in the ear; patients may also have nausea and vomiting. The cause is unknown, but may be due to overproduction of endolymph fluid. Initial management includes diuretics, low-salt diet, avoiding triggers (e.g. stress, fatigue, alcohol, flashing lights). Anti-emetics may help. Psychological problems (e.g. loneliness, isolation, and anxiety) are common. Endolymphatic sac surgery and vestibular nerve section are surgical treatments but the vast majority are treated medically and conservatively and do not require surgery.

Acoustic neuroma

This is a rare benign neoplasm of Schwann cells of the 8th cranial nerve that causes tinnitus, asymmetrical sensorineural deafness, and vertigo later. Treatment may be conservative, gamma knife surgery, or microsurgery. Patients tend to be nursed on a neurological ward.

Patients undergoing ear surgery

Myringotomy and insertion of grommets

A small incision is made in the tympanic membrane and a small tube (grommet) is inserted to ventilate the middle ear and prevent fluid and pressure accumulation. This is undertaken for glue ear mostly in children or malfunction of the eustachian tube in other age groups.

Specific preoperative care

includes baseline assessment audiogram, and impedance test, explanation of surgery and pre- and postoperative care for general anaesthetic as day case.

Specific postoperative care

includes lying in semi-prone position and resumed eating and drinking when awake. Pain is unusual and immediate improvement in hearing is common. Keep ears dry by using cotton wool and petroleum jelly when hair washing and bathing—remove afterwards. Advise not to clean ears with cotton buds and contact GP if earache occurs.

Myringoplasty

This is an operation under general anaesthesia to repair a perforation in the tympanic membrane (eardrum) using a small graft. Preoperative care is as for myringotomy and postoperative care is as for mastoidectomy. Avoid raising pressure in middle ear by avoiding vigorous nose blowing and keeping mouth open during sneezing.

Mastoidectomy

Surgical removal of affected tissue from the mastoid cavity under general anaesthesia.

Specific preoperative care

  • Obtain x-ray of mastoid area and hearing tests to act as baseline.

  • Explain surgery and pre- and postoperative care including sutured wound behind the ear and possibility of drain and pain relief.

  • Explain risks of surgery, e.g. slight risk of facial nerve damage and infection.

Specific postoperative care

  • Instruct patients to avoid lying on the operated side.

  • Monitor blood pressure, and pulse, and observe for facial nerve damage.

  • Administer pain relief and anti-emetics as required.

  • Patients may resume eating and drinking when conscious, if no vomiting.

  • Advise patients not to make sudden head movements.

  • Mobilize patient as soon as possible.

  • Remove pressure dressing using aseptic technique the following day and drain after 1–2 days.

  • Remove ear pack 10 days to 6 weeks later.

  • Explain about surgery and continuing care including suture removal after 1 week.

  • Advise to keep ear dry and inform GP if discharge is more than minimal or is offensive.

Stapedectomy

This is the removal of the stapes ossicle in the middle ear under general anaesthesia and replacement with a plastic prosthesis as a result of otosclerosis (fixation of the stapes at the oval window). Usually results in dramatic improvement in hearing but risk of deafness and balance problems in 2% of patients.

Preoperative care

includes audiogram and impedance tests, explanation of operation, risks and benefits, pre- and postoperative care.

Postoperative care

as for mastoidectomy.

Patients with hearing impairment

Types of hearing loss

Sensorineural hearing loss:

caused by disorders of the inner ear, cochlea, acoustic nerve, or central auditory pathway.

Conductive deafness:

caused by disorders of the external or middle ear that prevent sound from reaching the cochlea including congenital deformities (e.g. atresia of external ear), wax, perforation of eardrum, ossicular chain disorders, eustachian tube disorders, otitis media, and cholesteatoma (cystic growth in middle ear).

Presbycusis:

age-related hearing loss due to degeneration of the fine hair cells of the cochlea. High-frequency sounds are affected first.

Degree of hearing loss

Deaf:

people who are unable to use hearing for communication.

Hearing impaired:

people who can use hearing to some degree for communication. May be mild, moderate, severe, or profound, based on softest sound level (decibels) an individual can hear without amplification (mild 16–30 dB; moderate 31–70 dB; severe 71–90 dB; profound over 91 dB). A whisper is about 10 dB.

Aids to interpreting speech

Hearing aids:

are electronic battery-operated devices that are worn externally. They amplify and change sound and send it to the ear through a speaker. All sounds, including background noises, are amplified. Types of hearing aids include:

  • ‘Behind the ear’ (most common) and ‘body worn’ (best for profound hearing loss—the aid is attached to an ear mould)

  • ‘In the ear’ and ‘in the canal’—the aid is incorporated into the ear mould itself

Analogue hearing aids are being replaced by digital ones which can be programmed precisely to meet an individual’s hearing loss.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Hearing aid care, p.[link].

Cochlear implants:

are small electronic devices that are surgically implanted underneath the skin behind the ear. They convert sound waves into electrical impulses that the brain recognizes as sound.

Listening equipment

  • Loop and infrared systems help the listener hear sounds more clearly by reducing background noise. They may be found in theatres, cinemas, banks, and shopping centres. Smaller systems can be set up in the home.

  • Neckloops, earloops, loop amplifiers, or headphones can make listening to videos, TV, radios, and stereos easier by making sounds louder and clearer.

  • Subtitles on TV, videos, DVDs.

 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Communicating with hearing-impaired patients, p.[link].

Hearing aid care

Ear moulds

These are made to fit each ear and are not interchangeable. Cleaning should be undertaken regularly.

  • Detach the ear mould from the hearing aid.

  • Remove any wax that is blocking the tube and wash with soap and water.

  • Rinse the mould well and dry it thoroughly. Ensure the tubing is free of moisture. A special ‘puffer’ can be obtained from audiology departments for this purpose.

  • Do not detach the tubing from the ear mould unless it is being changed.

  • Replace the tubing about every 6 months as it becomes hardened and affects the performance of the hearing aid.

Batteries

  • Ensure that the battery is inserted correctly in the battery drawer. If there is any resistance, check that it is inserted with the proper side facing up. Incorrectly inserted batteries can cause extensive damage and, if privately bought, can be expensive.

  • To check the battery is working, turn the hearing aid on and turn the volume to maximum with the hand cupped round the aid. If it whistles, the battery is working. Never do this while the hearing aid is in the ear.

Controls

  • Usually consists of on–off switch (O=off), volume control, (M=microphone/on), and battery holder. There may be a ‘T’ setting which is for a telecoil loop system. The volume generally goes from 1–4 with 1 being the quietest. Adjust for the individual’s need at the time.

Communicating with hearing-impaired patients

Problems in communication

  • Staff often fail to recognize hearing impairment, which may be due to:

    • poor observation and history taking

    • difficulty in communication because of culture or language barriers

    • failure to communicate with each other.

  • Patients may conceal their disability.

  • Staff may lack skills or knowledge of how to communicate effectively with hearing-impaired people; may be due to poor training.

  • Facilities (e.g. minicoms, hearing loops, etc.) may be inadequate or staff may be unaware of how to use them.

Improving communication

  • Ask the patient if they are hearing impaired and what devices or techniques they use. Be aware that they may deny their disability.

  • Observe for signs of impaired hearing (e.g. inappropriate response to a question, smile, nod). This may be confirmed by turning away from the patient to ask a question so they cannot lip read.

  • Gain the patient’s attention by calling their name. Introduce yourself and others if present.

  • Create a conducive environment; reduce background noise (e.g. turn off TV, radio), use a quiet room with the door shut, and use a well lit room with adequate lighting for lip reading.

  • Speak slowly and clearly and at normal volume to increase clarity. This should not be done to the extent that makes the person feel stupid. Do not shout.

  • Face the patient and make sure your mouth is visible at all times and not hidden behind a hand. Do not wear sunglasses.

  • It may be helpful to state the topic of conversation to set the context.

  • Face the person with the hearing impairment if possible at about 1 m distance and at the same level. Use natural facial expressions, gestures, and body language and make sure these match the message.

  • Check that the person can follow you and rephrase if necessary.

  • Give time for the patient to interpret what is being said and to make responses. Be patient.

  • Follow up important discussions with written information and repeat conversations if necessary.

  • It may be helpful to have a sign language interpreter if the patient uses sign language.

Special communication techniques and equipment

British Sign Language and Sign Supported English

British Sign Language (BSL) is the most widely used method of signed communication in the UK. It uses both manual and non-manual components and hand shapes and movements, facial expression, and shoulder movements.

Finger spelling

Often used in conjunction with BSL. Certain words, often names of people and places, are spelled out on fingers.

Equipment

  • Alarm clock with flashing lights and vibrating pads.

  • Fire alarms with flashing lights.

  • Extra loud door bells or combined with flashing lights.

  • Telephones with flashing lights, extra amplification, and induction loop to enable people with hearing aids to use the ‘T ‘setting on the aid with the phone.

  • Text phones.

  • Video phones to communicate with sign language.

  • Subtitles on TV.

  • Hearing loops attached to TV, radio, and hi fi equipment.

  • Hearing loops set up in theatres, community halls, etc.

Nursing care of patients with ear problems

Ear pain

Pain may be severe if due to trauma, furunculosis (infected hair follicle) in external canal, and otitis media. It may be less severe in otitis externa and perforation of the eardrum. Pain, swelling, and tenderness behind the ear occur with mastoiditis. Give prescribed analgesics and monitor and record effects. Insulated heat pad may help make the patient feel more comfortable.

Ear discharge

Bleeding may occur as a result of trauma, infection, perforation of eardrum, or basal skull fracture. Cerebropsinal fluid (CSF) may leak with basal skull fracture. Offensive discharge occurs in infections of the outer and middle ear, and with foreign bodies ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) External ear conditions, p.[link]). If due to infection give prescribed antibiotics, and record and monitor effects. Explain effects and side effects of antibiotics. Perform aural toilet using cotton wick to gently remove debris. Remove foreign body with instruments only if specifically trained and if superficial.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 13, Head injury, p.[link].

Impaired hearing

The degree of hearing loss varies from mild to profound and may be temporary or permanent, gradual, or sudden onset. It may result in long-term speech and language problems.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Patients with hearing impairment, p.[link].

Communication problems

Some patients may have to interpret speech without sound and use a combination of lip reading, body language, facial gestures, and the context of the conversation. Others rely on visual communication, e.g. sign language. Some may be helped by hearing aids. Hearing aids may not work because of flat batteries, blocked tubes, and ill-fitting ear moulds.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Communicating with hearing-impaired patients, p.[link].

Loss of balance, vertigo

This is caused by inner ear problems. It may be accompanied by dizziness and giddiness; patient may experience falls or ‘drop attacks’ if vertigo is sudden and intense. Attacks vary in severity and vary in duration from a few minutes to hours. Administer anti-emetic and vestibular suppressant if prescribed in severe cases. Do not move the patient’s head unless essential; support the head. Advise the patient to lie on the unaffected side; keep the room dark and free from noise. Speak calmly and quietly. Physiotherapy and specific exercise may help.

Nausea and vomiting

These may occur as a result of disturbances in balance associated with problems of the inner ear; may also occur in infections. Keep vomit bowl close by and change after use. Apply cold face cloth to forehead if the patient is sweating. Give prescribed anti-emetics and give mouthwashes as required.

Anxiety

This may be due to possible deterioration of hearing leading to profound deafness or due to fears that the treatment and tests may be painful or that the condition may have a poor prognosis. Encourage patient to discuss fears and listen to them. Give information to enable patient to make decisions, understand prognosis, treatment, care, and the future.

Social isolation

This may occur because people may be impatient with hearing-impaired people and treat them as less intelligent. Inability to follow conversations may lead to lack of confidence and being ignored by others. Encourage patient to share their disability, and what it means to them, with others. This will enable family, friends, and work colleagues to understand why they are behaving as they do, to be patient, and to take special measures to ensure more effective communication.

Safety risks

Patients with hearing impairment may not hear alarms, e.g. smoke detector fire alarms, car horns, etc. While in hospital special precautions must be made for patients with hearing impairment, e.g. patient needs to be informed in person when fire alarm sounds.

Preoperative care

Follow the principles for preoperative preparation. Teach postoperative techniques, e.g. instilling ear drops. Follow local procedures for preparation of the ear area—a small area behind the ear may be shaved, e.g. in mastoidectomy. Check the consent form has been signed and answer any further questions about risks and consequences of surgery.

Postoperative care

Position the patient in the most comfortable position but avoid lying on operated side; observe temperature and blood presure, and for bleeding and damage to the facial nerve (weakness on side of face). Advise avoiding sudden head movement which may result in dizziness, nausea, and vomiting. Give pain relief. Encourage patient to resume eating and drinking when nausea and vomiting subsides. Time to start to mobilize will vary depending on patient and operation—support patient in case of dizziness.

Removal of ear wax

Impacted ear wax is one of the most common ENT reasons people visit their GP.

  • To examine the external canal:

    • Explain to the patient what is planned.

    • Use an auroscope with the largest speculum that will fit comfortably into the canal.

    • Gently pull the pinna upwards and backwards to straighten out the canal.

    • The tympanic membrane should be visible but may be obscured by impacted wax.

    • Observe for any inflammation or infection.

  • Take history to determine whether the eardrum has been perforated ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Nursing assessment of patients with ear problems, p.[link]) or whether there have been any injuries or previous surgery or infections.

  • In certain circumstances irrigation may be contraindicated, e.g. uncooperative patient, acute otitis externa, previous ear surgery, cleft palate (repaired or not), perforation of eardrum, complications with previous irrigation, or recent or current middle ear infections.

  • Use ear drops to soften the wax for 5–7 days and 2–3 times per day. Olive oil, water, and saline drops or commercial drops can be used (none has been found to be more effective than others).

  • Insert the drops at night and ask the patient to lie with the treated ear uppermost for a time to allow the drops to penetrate the wax.

  • If this fails to clear the wax, irrigation is necessary using an electrical pulsed water irrigator.

    • An internal pump sends pulses of water through a nozzle into the canal.

    • The operators should have training in using this technique and cleaning and care of the equipment.

    • Explanations should be given to the patient and consent obtained.

    • Examination of the external canal immediately before and after syringing is required.

  • Auroscopes, speculums, and irrigators should be decontaminated following use.

  • Ensure the procedure, result, treatment, and advice given are documented following local policy.

  • If contraindicated, failure, or complications arise refer to ENT for microcsuction.

Education for patients with ear problems

Patients with existing ear problems

  • Use a model of the ear to explain the patient’s condition and what will happen during and as a result of treatment and surgery.

  • Explain the importance of handwashing and other actions to prevent infection before, during, and after ear care.

  • Teach the patient and carer how to instill ear drops, care for hearing aid and change batteries, and ensure they know how to use any other equipment ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Special communication techniques and equipment, p.[link]). Supervised practice is preferred.

  • Explain how to keep the ears dry during bathing, hair washing, and swimming by using petroleum jelly on cotton wool plugs. Advise that these should be removed afterwards.

  • Explain ‘what to do’ and ‘what not to do’. These will vary depending on the condition. Avoid strenuous exercise, heavy lifting, and straining following stapedectomy; keep ear dry following myringotomy. Avoid air travel, diving, or other situations causing pressure changes in the ear for a specified period.

  • Encourage patients to ask questions and express fears about their condition, care, treatment, and the future and longer-term prognosis.

  • Discuss the possible consequences of concealing deafness from others. Advise that family, friends, and work colleagues can give support if they are aware of the disability.

  • Suggest ways of improving communication and overcoming problems ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Communicating with hearing-impaired patients, p.[link]).

  • Ensure patient is seen by specialists (e.g. speech and language therapists, audiologist for specialist education) and arrange for programmes such as sign language, lip reading.

Preventive education

  • Advise patients not to clean ears or attempt to remove wax with cotton buds or any similar equipment because of the danger of impacting wax or damaging the eardrum.

  • Advise patients to wear ear protection if working in a noisy environment. This should be provided by the employer and they may be eligible for compensation if protective equipment has not been provided.

  • Advise patients to contact their GP if they think they have a hearing loss or another ear problem.

Discharge and continuing care for patients with ear problems

  • Follow the discharge process.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 38, Discharge planning, p.[link].

  • Check the patient (and/or carer):

    • Understands their condition and plan for the future.

    • Understands their ear care requirements.

    • Is able to instill ear drops properly.

    • Has the required medication, understands the use, side effects, and consequence of non-compliance and where to get repeat prescriptions.

    • Has their hearing aid, knows how to use and maintain it, and where to get batteries and other help and advice.

    • Has received specific instructions relevant to their condition.

  • Arrange for dressing changes or removal; removal of sutures; return to ward; visit to outpatients; or visit by community nurse or specialist nurse.

  • Convalescence period will be determined by the individual and their condition.

  • Arrange for follow-up at outpatients with the nurse specialist or consultant, or with GP, or with the audiology department.

  • Provide information on how to register as hearing impaired or deaf.

  • Ensure patient and carer have information about the legal obligations of:

    • Employers who are required to treat deaf people as favourably as hearing people and to make reasonable adjustments to ensure deaf people are not disadvantaged.

    • Education providers to make reasonable adjustments to support deaf students.

  • Ensure patient and carer are aware of local and national voluntary and support services and networks ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Further information on ear disorders, p.[link]) and are aware of Disability Employment Advisers at Job Centres who can assist people with hearing impairment to find jobs.

  • Ensure the patient is aware of support that social workers can provide for deaf people.

  • Ensure the patient and carer know how to access equipment, programmes, and interpreters that will help improve communication and ensure safety, e.g. smoke detectors with flashing lights and vibrating pads.

Further information

Royal National Institute for the Deaf (RNID): RNID Tinnitus Helpline (information and advice on tinnitus) RNID Sound Advantage (range of equipment for deaf and hard of hearing) RNID information line (range of information on deafness and hearing loss) www.rnid.org.uk Links to:

Vestibular Disorders Association: www.vestibular.org

Ménière’s Society: www.menieres.org.uk

National Institute on Deafness and Other Communication Disorders: www.nidcd.nih.gov/health/pubs

British Deaf Association: www.bda.org.uk

Hearing Concern: www.hearingconcernlink.org

National Deaf Childrens’ Society: www.ndcs.org.uk

ENT Nursing information sheets: www.entnursing.com

Information regarding ear care: www.earcarecentre.com

Nursing assessment of patients with nose and throat problems

In addition to a general nursing assessment ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 3, Individualizing nursing care practice, pp.[link][link]) perform the following procedures.

Observe the patient

  • Signs of trauma to the nose, e.g. swelling, deformity, dislocation, epi-staxis, and soft tissue injury.

  • Signs of injury to the throat, e.g. airway injuries causing stridor, cough, obstruction, haemoptysis, pain, internal and external bleeding, tissue damage.

  • Epistaxis: note the amount and location of bleeding, whether bleeding is from both nostrils; does the patient spit blood out? Take blood pressure, and pulse.

  • Nasal discharge: whether clear, purulent, bloody, foul smelling, from one or both nostrils, any excoriation around nostrils.

  • Dysphonia: difficulty with speech and hoarseness, e.g. due to inflammation of the larynx, pharynx, tonsillitis.

  • Dysphagia: difficulty swallowing, e.g. in tonsillitis, foreign body, or due to neurological cause.

  • Airway obstruction due to infection, swelling (e.g. epiglottitis), foreign body. Check respirations (rate, depth, stridor) and patient’s colour as patients may deteriorate rapidly and require immediate medical intervention.

  • Signs of fever, e.g. in tonsillitis, peritonsillar abscess, epiglottitis. Take temperature and pulse.

Ask the patient about

Nursing history

  • Ability to manage self-care and activities of daily living

  • Social situation (dependants at home, anyone to care for them)

  • Past and present nursing problems

  • Psychological and spiritual assessment

  • Lifestyle, e.g. sports (e.g. rugby player, boxer), singer, actor, use of recreational drugs (cocaine)

  • Fears and anxieties about the nose and throat condition and prognosis; effects on appearance, lifestyle, and ability to sleep; what they understand about the condition and the care and treatment planned

Potential nursing problems

  • Epistaxis—duration of previous episodes, known causes

  • Nasal discharge and irritation

  • Sore throats—whether recurrent, the duration, known causes

  • Dysphagia, dysphonia, hoarseness—duration, extent

  • Fever—duration, whether accompanied by nausea, headache, anorexia

  • Pain—location, duration, methods of pain relief used

  • Breathing problems—obstruction in nasal passages or larynx

  • Loss of smell and taste disturbances

Medical history

  • Drugs (aspirin, NSAIDs, warfarin, cocaine, and nasal sprays are linked to nose bleeds, antibiotics)

  • Hypertension

  • Recent upper respiratory infections

  • Tonsillitis

  • Dental problems, allergies, and rhinitis (associated with polyps)

  • Previous nose and throat surgery and tracheostomy.

Nursing patients with nose and throat problems

Epistaxis

This is a nose bleed. With anterior epistaxis, blood drips from the nose (one or both nostrils). With posterior epistaxis, blood drains down the back of the throat. Blood can be profuse and may be swallowed and therefore not visible.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Epistaxis, p.[link].

Nasal discharge

This may be clear, CSF (after trauma and fracture;  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Trauma, p.[link]) serosanguinous, offensive, infected, and may be from one or both nostrils. Post-nasal drip is common in sinusitis and polyps and may give rise to a sore throat.

Dysphagia

This is difficulty in swallowing fluids and/or solids.

Dysphonia and hoarseness

These refer to difficulty in speech and changes in the quality, volume, and resonance of the voice.

Pain

This may be sore throat, earache (referred pain from tonsillitis or peritonsillar abscess), headache and facial pain (sinusitis) located over site of trauma (e.g. nose, throat), or due to infection (e.g. furunculosis of nose).

Fever

This is raised temperature, often with malaise.

Airway obstruction

The extent of the obstruction is variable depending on the cause. A foreign body in the nose or nasal deformity may cause an obstruction to the airflow through the nasal passages, but conditions such as epiglottitis obstruct the laryngeal opening causing complete obstruction.

Loss of smell and taste

This may result in loss of appetite.

Anxiety

This may be due to recent events (e.g. trauma event); fear of prognosis or that the treatment and tests will be painful; or about arrangements for dependants.

Social isolation

Difficulty with speech and hoarseness may make the individual reluctant to join conversations.

Nose and throat tests and investigations

For all tests and investigations explain the procedure to the patient, obtain consent, and provide support throughout.

Laryngoscopy

Indirect laryngoscopy

is used to assess the mobility of the vocal cords or to rapidly assess the hypopharynx to exclude or locate foreign body. A warmed laryngeal mirror is introduced onto the soft palate and the laryngeal structures are viewed by tilting the mirror; the image is reversed.

Fibre-optic laryngoscopy

is used to visualize the entire nasopharynx and larynx. A flexible endoscope is introduced through the nose after topical anaesthesia (e.g. cocaine) has been applied. This is valuable in patients who experience severe gagging or who are uncooperative. It is essential for patients who need thorough laryngeal examination, e.g. when cancer is suspected.

Rigid endoscopy

is performed under general anaesthesia. Check for loose teeth, caps, crowns, or bridges; warn of small risk of tearing of the oesophagus and the possibility of a sore throat and swallowing difficulty. A biopsy may be taken. The patient may notice spotting/streaking of blood mixed with secretions. Advise to seek advice if voice changes or new symptoms develop, e.g. neck lumps, earache, facial pain.

Laboratory tests

These will vary depending on operation, age, and any underlying condition and may include FBC, group, cross-match and save, prothrombin time (PT), and partial thromboplastin time (PTT).  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 39, Common laboratory tests and their interpretation, p.[link].

X-rays

Plain x-rays of sinuses are taken to identify fluid levels and mucosal thickening in sinusitis. Lateral pharyngeal (neck) x-rays may be taken to evaluate the size of the adenoids. CT scans are used to evaluate sinus disease and to identify the size and location of tumours.

Culture and sensitivity tests

Throat culture

is performed if bacterial infection is suspected, e.g. high temperature, abrupt onset of symptoms, patient appears ill, or elevated WBC. Depress patient’s tongue with a spatula, use flashlight to see inflamed area, sweep swab over area without touching lips or tongue. Transport in transport medium that has been correctly labelled.

Nasal and nasopharyngeal cultures

are used to identify carrier organisms or to screen for infection. For nasal culture a flexible swab is inserted into the nose and rotated against anterior nares. A longer flexible swab is required to collect specimens from the posterior pharynx. Transport in transport medium that has been correctly labelled.

Sinus washout

refers to the introduction of water or saline solution into the maxillary sinus to remove infected material under local anaesthetic or general anaesthetic. Send material for culture. Introduction of the trocar causes cracking noise. This is an unpleasant procedure under local anaesthetic.

Conditions of the nose

Foreign body

Usually occurs in young children—beads, cotton wool, seeds, and sweets are common. It is usually unilateral and may be asymptomatic or produce offensive or blood-stained discharge. If accessible in the anterior part of nose, it can be removed with instruments by a specially trained practitioner. There is a danger of dislodging with subsequent inhalation. Removal under general anaesthesia may be necessary if child is uncooperative.

Trauma

This may result in fracture of nasal bones, nasal septum, or septal haematoma. Fractures may be simple (skin and mucosa intact) or compound (cartilage and bone are exposed). Patients may present with nasal deformity, swelling, obstruction, epistaxis, and soft tissue injury. Reduction of the fracture may be done immediately or after 7–10 days when the swelling subsides.

Nasal polyps

These are pedunculated sacs that are usually bilateral and often allergy related. They cause nasal obstruction, watery discharge, post-nasal drip, and sneezing. They may develop purulent discharge, if infected. They are more common in men. Treatment includes topical steroid drops or systemic steroids or surgical removal. They may recur.

Sinusitis

This is inflammation of mucous membrane of the paranasal sinuses due to obstruction, infection, or allergy. It may present with headache, facial pain, blocked nose, post-nasal drip, and changed voice resonance. Treatment is with antibiotics, analgesia, decongestant, and possible irrigation under general anaesthesia.

Epistaxis

Anterior

is commonly seen in children. Blood drips from one or both nostrils. It is usually due to nasal dryness, facial injury, sneezing violently, nose blowing or picking, foreign bodies, or common cold.

Posterior

is seen more often in older people. It may be caused by underlying health problems (e.g. hypertension, diabetes, tumours) or may be aggravated by drugs (e.g. warfarin, cocaine, aspirin). Use digital pressure to stop bleeding ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Control of epistaxis by digital pressure, p.[link]). If unsuccessful, invasive measures may be necessary, e.g. nasal packing, topical vasoconstrictor, cauterization with chemical agent such as silver nitrate sticks, or using intranasal balloon pack, balloon tamponade, or arterial ligation under general anaesthesia.

Tumours

Benign tumours

include nasal ostoma (rare), nasal papilloma (common wart-like growths), and nasal angioma (causes epistaxis, requires surgical excision).

Malignant lesions

are not common. They may cause blood-stained discharge, nasal obstruction, facial swelling, and lymph nodes in neck. Prognosis is poor because of late presentation.

Control of epistaxis by digital pressure

  • Pinch the fleshy part of the nose, using the thumb and forefinger to reduce the blood supply for 10 minutes; it may require up to 30 minutes.

  • Keep the patient sitting up with their head forward to prevent blood entering the post-nasal space.

  • Use an ice compress over the bridge of the nose, back of neck, or both to promote vasoconstriction.

  • Do not allow the patient to blow their nose or to sniff. Provide a bowl to expectorate.

  • Wear protective clothing—gloves, mask, and eye protection as coughing or sneezing may result in blood particles being aerosolized.

  • Note the duration, amount, and location of bleeding.

  • Act in a calm manner and reassure the patient who will be anxious and frightened.

  • Assess the patient’s vital signs for decrease in blood pressure and increased pulse and respirations; observe colour and temperature of skin and nail beds for pallor and cyanosis.

Prevention of further epistaxis

Advise the patient to:

  • Not blow their nose for a week.

  • Not lift heavy objects for a week.

  • Keep the head upright when bending down.

  • Not use nasal sprays unless prescribed by doctor.

  • Avoid people with influenza or colds.

  • Avoid smoky atmosphere.

  • Not pick nose.

  • Avoid hot fluids immediately after nose bleed (causes vasodilation).

Nursing care of patients undergoing nose surgery

Surgery of the nose

Nasal polypectomy

Polyps are removed under local or general anaesthesia and sent for histology. Unilateral polyps are more often malignant.

Nasal septoplasty

The septum between the nostrils may become damaged after trauma. Surgery involves lifting the mucosa, trimming the cartilage, and replacing the mucous membrane. Silastic nasal splints may be used to prevent adhesions and are removed by the nurse 7 days later.

Functional endoscopic sinus surgery (FESS)

Chronic sinusitis results in abnormal mucus production and drainage. FESS aims to restore normal drainage by correcting anatomical abnormalities, removing mucosa if diseased, removing polyps, and enlarging drainage via an endoscope.

Specific preoperative care

Preoperative assessment may be carried out 1–2 weeks before and the patient is usually admitted on the day of operation.

  • Ensure patient understands operation, risks, and benefits and that consent form is signed.

  • Perform blood tests (e.g. FBC) and x-rays of nose/sinuses.

  • Check on allergies and baseline vital signs.

  • Obtain CT scan of sinus to provide an anatomical road map.

  • Note medication, particularly use of nasal sprays, anticoagulants, aspirin.

  • Advise that packs will be in place postoperatively and that mouth breathing will be necessary and takes time to get used to.

  • Ask about loose teeth, caps, crowns, and bridges that may become dislodged.

  • Encourage questions and discussion about fears and feelings.

  • Instruct patient to fast as necessary.

Specific postoperative care

  • Nurse patient in most comfortable position.

  • Provide reassurance to help patient cope with feelings of not being able to breathe due to packs.

  • Observe for bleeding and signs of infection; take temperature and blood pressure.

  • Give mouthwashes to keep mouth fresh.

  • Encourage patient to eat and drink when recovered; lack of appetite may occur because of mouth breathing and difficulty in swallowing.

  • If blood oozes through nasal packs, prepare ‘nose-bag’ (pads of gauze).

  • Nasal pack is usually removed after 24 hours; warn patient that a long length of gauze may have been used and bleeding may occur.

  • Discharge should be after packs have been removed.

  • If necessary, give mild pain relief (e.g. paracetamol).

  • Convalescence will vary but patient should be at work after 2 weeks and should be fully recovered by 6 weeks.

Complications

  • For nasal polypectomy—haemorrhage and infection.

  • For nasal septoplasty—infection and haematoma, which presents with severe pain and total nasal blockage, and requires readmission, incision draining, and usually antibiotics.

  • For FESS—haemorrhage, haematoma, pain, infection, and rarely CSF leak or loss of vision. Rapid eye swelling due to bleeding into the eye socket is an emergency post FESS and must be recognized and treated promptly to prevent blindness.

Conditions of the throat

Tonsillitis

This is commonly caused by group A beta-haemolytic streptococci. Patient typically presents with sore throat, dysphagia, fever, malaise, headache, cervical lymph glands, and exudate on the tonsils. Throat swabs do not give instant results; antibiotics are not always given as side effects outweigh benefits. Give prescribed analgesia, antipyretics, and antibiotics if prescribed (usually penicillin); encourage fluids and rest. May develop into:

  • Peritonsillar abscess (quinsy) occurs unilaterally mostly in adults, resulting in worsening of symptoms, earache, dysphagia, and trismus (difficulty opening jaw). Requires antibiotics and drainage of abscess under general or local anaesthesia.

  • Recurrent or chronic tonsillitis refers to repeat or prolonged episodes of tonsillitis.

  • Tonsillectomy is considered for patients with recurrent tonsillitis, airway obstruction, sleep apnoea, quinsy, suspected malignancy.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Tonsillectomy (removal of tonsils), p.[link].

Laryngitis

This is inflammation of the larynx. It is usually viral and is exacerbated by overuse of the voice, smoking, and drinking spirits. It causes hoarseness and laryngeal pain; larynx is red and dry. Management includes resting voice, inhaling steam, and avoiding precipitating factors. Antibiotics are rarely needed.

Acute epiglottitis

This is a localized bacterial infection, usually Haemophilus influenzae. It is more common in children, but is less common since HIB vaccination. It causes swelling of the epiglottis, increasing dysphagia, stridor, and obstruction of the larynx. High-dose IV steroids are prescribed; humidified oxygen is essential. Emergency intubation or tracheostomy may be required. A calm atmosphere and support is required for parents and child.

Foreign body

Fish and meat bones, sharp objects, and button batteries are common. These may impact in tonsil, pharyngeal wall, obstruct the airway, or be swallowed. It results in sharp local pain, retrosternal pain, worsening dysphagia, increased salivation, and airway obstruction. The foreign body may be identified on x-ray. An ENT specialist is required for removal; an emergency laryngotomy or tracheosotomy is necessary for complete airway obstruction. Observe for raised temperature, and chest or back pain suggesting perforation.

Laryngeal carcinoma

This is the most common head and neck tumour, usually squamous cell carcinoma. Smoking is main risk factor. Patient presents with hoarseness, pain, dysphagia, sore throat, and stridor. Diagnosis is by laryngoscopy and biopsy; treatment is by surgery and radiotherapy. Prognosis is good if detected early.

Advice for patients with voice problems

  • Save your voice as much as possible—speak quietly and limit talking.

  • Avoid speaking for long periods, shouting, or raising your voice. Stop speaking if voice deteriorates. Do not whisper—this strains the voice more.

  • Keep throat and mouth moist with soft drinks but avoid tea, coffee, and alcohol which have a drying effect. Avoid very hot drinks.

  • Do not smoke and avoid smokey atmospheres as these damage the throat.

  • Keep air humidified by using a humidifier or keeping a bowl of water nearby or wet towel on radiator to produce steam.

  • Try to relax; use yoga or relaxation techniques to reduce tension in back, neck, and jaw.

Nursing care of patients undergoing throat surgery

Laryngectomy

This is removal of the larynx, usually because of malignancy. Patients will not be able to speak using their vocal cords and need a new method of communication.

Preoperative care

Preoperative assessment may be carried out 1–2 weeks before and patient is usually admitted a day before operation.

  • Obtain FBC, group and cross-match, chest x-ray, and baseline temperature and blood pressure.

  • Ensure patient understands surgery, risks, and planned outcomes, particularly about loss of voice and the presence of a permanent stoma with tracheostomy tube.

  • Explain how coughing and breathing will occur and that an IV infusion, fine-bore nasogastric tube, and drains will be in situ.

  • Discuss prognosis and encourage patients to ask questions and express feelings.

  • Refer patients to a physiotherapist and a speech and language therapist to learn about care postoperatively.

If appropriate, arrange a visit by a person with a laryngectomy who is leading a full life for the patient and family to talk to.

Postoperative care

  • In immediate period, as for tracheostomy.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Nursing care of tracheostomy patients, pp.[link][link].

  • Drains are removed 2–3 days after operation.

  • Hydration and nutrition is through enteral feeds and IV infusion until wound heals; check with barium swallow, then commence soft diet (after 10–14 days).

  • Removal of sutures is after 7–10 days.

  • Teach patient how to care for stoma and provide alternative methods of communication ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Communicating with patients following laryngectomy, p.[link]).

  • Be patient, provide support in helping patient towards self-care, and take time to listen to their feelings and anxieties.

  • Any ventilatory support in resuscitation must be given via stoma.

Tonsillectomy (removal of tonsils)

Specific preoperative care

  • Ensure patient (and parents) understand the surgery, care, and potential benefits and risks including postoperative haemorrhage, hypernasal speech, airway obstruction, and very rarely death.

  • Explain what they might feel like postoperatively, e.g. soreness, reluctance to eat.

  • Obtain preoperative blood test for FBC and cross-match.

  • Identify recent respiratory problems, e.g. asthma, sleep apnoea.

  • Check for medications (e.g. aspirin) and discontinue these, and for allergies.

  • Encourage parent(s) to stay with child.

  • Check baseline temperature and blood pressure.

Specific postoperative care

  • Nurse semi-prone initially.

  • Observe for bleeding (check mouth, throat for excessive swallowing, raised, weak pulse, low blood pressure), fever, respiratory distress, pain (analgesia and mild sedatives might help).

  • Encourage sips of cold clear fluid when alert, then ice cream and jelly, then introduce normal diet as soon as possible.

  • Keep mouth clean, brush teeth as normal.

  • Give pain relief.

  • Patients are usually discharged home the next day. Provide discharge instructions on complications (e.g. earache, dehydration, secondary bleeding), keeping mouth clean, pain relief, return to activities, school, and work, and action to take if problems arise.

Communicating with patients following laryngectomy

Probably the greatest cause of concern for both tracheostomy patients and laryngectomy patients is the loss of speech and ability to communicate verbally and subsequent isolation. Explanations are important.

  • Patients with permanent tracheostomy and laryngectomy need to understand that alternative means of communication should be developed. Staff need to be sensitive to the impact of this news on both the patient and their family and give time for questions and discussion about what it means to them.

  • In the immediate postoperative period a writing board and pens, signs, boards, and picture boards will help with communication and the patient may be able to mouth words.

    • Allow additional time for the patient to respond as writing takes longer.

    • Speak in a normal tone. Although the patient cannot speak they may not be deaf.

  • Provide a bell or buzzer that will enable the patient to alert staff.

  • Remember the general principles of communication: speak in normal voice and at normal rate, face patient, and keep normal levels of eye contact. If you do not understand the message, say so.

  • In the longer term patients may use artificial means of communication.

    • Oesophageal speech—pockets of air are retained in the oesophagus and forced into the mouth while words or syllables are mouthed.

    • Electrolarynx—a hand-held battery-operated device produces electronic vibrations that are placed on the throat and the patient forms words which the vibrations turn into sounds.

    • Tracheo-oesophageal puncture—a voice prosthesis is inserted into a surgically created fistula and the patient speaks by forcing air through the prosthesis into the oesophagus and into the mouth where words are formed. The vast majority of patients attain speech using this method.

  • Speech and language therapists are essential to advise, support, and teach the patient and family.

  • Give information about help and support groups.

  • Provide written information as well as giving explanation and having discussions.

  • Suggest the patient uses text messaging if possible, instead of phoning.

Nursing care of tracheostomy patients

Tracheostomy

This is an opening in the anterior wall of the trachea; it may be temporary or permanent to facilitate ventilation, e.g. reduce effort of breathing in respiratory failure, bypass upper airway obstruction, support assisted ventilation, and remove bronchial secretions.

Nursing care and overcoming problems

  • Patient will be in a high-dependency area or ITU initially; closely monitor blood pressure, pulse, and respirations every 30 minutes to 1 hour.

  • Prevent accidental extubation. Ensure tracheostomy ties are secured. Keep emergency equipment at hand—tracheal dilators, spare tracheostomy tubes (one same size and one smaller), suction and suction catheters, syringe, scissors, and stitch cutters if tracheostomy is stitched in. Tracheal opening is held open with dilators until the replacement tube is inserted.

  • Suction if cough reflex is ineffective or secretions are thick. Choose correct catheter, Fg10–12 should be sufficient; use 80–120 mmHg pressure. Should be done only by experienced staff trained in technique.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Tracheostomy suctioning, p.[link].

  • Provide artificial warmth and humidity. Initially humidified oxygen is given, then air can be provided through heat–moisture exchanger. This helps to prevent respiratory distress from inhaling cooled air and drying and thickening of mucus. Keep patient well hydrated and give saline nebulizers frequently.

  • Reduce risk of infection. Follow a sterile or non-touch technique and hand decontamination for dealing with the tracheostomy and suctioning. Change humidification equipment daily. Monitor for signs of infection, take temperature, send swabs for culture as appropriate (e.g. secretions, wound). Ensure regular physiotherapy, change of position, and deep breathing to inflate lung bases.

  • Perform wound care. Keep clean and dress with tracheostomy dressing to absorb drainage and prevent damage to neck tissue. Clean skin around tube with normal saline to prevent collection of secretion and soreness. Change tapes as necessary when soiled. May require two people to prevent accidental extubation and respiratory arrest. Teach patient self-care if permanent tracheostomy.

  • Manage blocked airway, e.g. by mucus plug. Summon help urgently, use suction; if still not removed, deflate tracheostomy cuff with syringe to allow small volume of air to bypass. Give oxygen at 100%. Remove and replace tracheostomy tube by skilled practitioner.

  • Provide pain relief. May be IV or through syringe pump for 1–2 days, then IM.

  • Patient can mobilize from first postoperative day if fit.

  • Diet and fluids to start as soon as patient is able.

Tracheostomy suctioning

Should only be undertaken by specially trained experienced professional.

Indications

  • Ineffective cough or no cough (ventilated patient)

  • Thick secretions

  • Chest sounds wet or ‘bubbly’

  • Increased coughing and ineffective airway clearing

Catheter size

Should be no more than half the diameter of the inner lumen of the tracheostomy tube.

Suction pressure

  • 80–120 mmHg

  • If too low, suction is ineffective

  • If too high, damage to mucosa, airway collapse, or ulceration may occur

Procedure

  • Explain and reassure the patient as this can be a frightening procedure and it may make them cough.

  • May need to pre-oxygenate with 100% oxygen to prevent hypox-aemia during the process.

  • Use sterile technique with gloves, protective goggles, and mask.

  • Use a fresh catheter each time and insert about 13 cm (approximately 6 inches) into the trachea. Do not apply suction during insertion, only on withdrawal.

  • Time from insertion to removal of the catheter should be no longer than 10–15 seconds.

  • Patient should rest between each suction application.

  • Correctly dispose of the catheter.

Education for patients with nose and throat problems

  • Use diagrams and models to help explain condition, procedures, and planned effects of treatment, care, and/or surgery.

  • Provide written information to supplement verbal explanations.

  • Discuss with patients what it is like to have bilateral nasal packs and the need for mouth breathing or loss of voice following tracheostomy and laryngectomy.

  • Explain the importance of handwashing and other actions to prevent the spread of infection when administering nasal drops, changing tracheostomy tubes, etc.

  • Teach the patient and/or carer how to undertake specific aspects of care, e.g. administer nasal drops, nasal sprays, care of tracheostomy.

  • Advise on how to keep nose clean, e.g. use saline in a nasal spray to loosen dried mucus rather than picking and blowing, which may lead to damage or bleeding.

  • Explain about pain, how it should diminish, and pain relief to be used.

  • Explain ‘what to do’ and ‘what not to do’ to prevent complications.

    • Avoid alcohol for one week after polypectomy, nasal surgery, and tonsillectomy (causes vasodilation and risk of bleeding).

    • Use mouthwashes as well as brushing teeth to keep mouth clean and fresh to prevent infection and halitosis.

    • Drink fruit juices and water to ensure adequate hydration.

    • Do not allow water into stoma.

    • Protect scars with scarfs or sunblock.

  • Encourage patient to ask questions and express fears and feelings about prognosis, care, and treatment.

  • Ensure patient understands the use and effects of medication prescribed and any side effects.

  • Ensure parents/carers know what to do in emergency situations, e.g. accidental extubation of tracheostomy tube, secondary bleeding following tonsillectomy.

Preventive education

  • Suggest patients with recurrent nose bleeds and tracheostomy consider using humidifiers at home, especially when air is cold and dry, to prevent drying of mucosa.

  • Advise patients to use protective equipment for sports to avoid head and nasal trauma.

  • Advise patients and parents how to use digital pressure to stop nose bleeds.

  • Ensure patients and parents understand why antibiotics are not prescribed in certain circumstances, e.g. in viral causes of sore throat, laryngitis.

Nasal douching

Aims to remove debris following surgery and keep nose and sinuses clean and healthy. Use the following solution:

  • 1 teaspoon salt

  • 1 teaspoon sugar

  • Pinch bicarbonate of soda

  • ½ pint tepid water

Procedure

  • Put solution in a saucer or shallow bowl.

  • Block off one nostril with a finger.

  • Sniff up the solution into the other nostril.

  • Let the solution run out.

  • Sniff hard to clean out old blood clots or mucus.

  • Continue until debris is no longer being washed out.

  • Repeat on other nostril.

  • Douche 3 times a day; then reduce as nose becomes clearer.

  • Nose drops, if prescribed, should be taken after douching.

Discharge and continuing care for patients with nose and throat problems

  • Follow the discharge process.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Chapter 38, Discharge planning, p.[link].

  • Check patient and/or carer:

    • Understands the specific ongoing care required, e.g. tracheostomy care.

    • Knows how to instill nasal drops, use nasal or throat spray.

    • Has medication, knows use and side effects, and where to get additional prescriptions.

    • Has specific written information relevant to their condition and discharge arrangements and support.

    • Knows action to take in the event of complications.

  • Ensure patient education has been undertaken.  							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Patient education for patients with nose and throat problems, p.[link].

  • Explain typical convalescence and when to resume activities. Varies with type of condition, age, and general condition.

    • Swelling, nasal obstruction, and discomfort subsides and sense of smell returns over 2 week period for nose operations.

    • Sore throat and discomfort following tonsillectomy returns over 2 weeks.

    • Return to work and school should be around 2 weeks; longer for tracheostomy and laryngectomy patients.

    • Advise to rest when tired.

  • Arrange follow-up appointment with ENT, GP, specialist nurses, and speech and language therapist.

  • Ensure patient and carer have information about local and national support groups, e.g. National Association of Laryngectomy Patients.

  • Ensure patient is aware of support social workers can provide for people with communication problems.

  • Advise patient on use of MedicAlert bracelet for stoma and need for resuscitation to be via stoma.

  • Ensure patients with tracheostomy and/or laryngectomy have information on and/or appointments with agencies to support alternative means of communication.

  • Ensure patient has contact number to ring for concerns and queries.

Common drugs used for ear conditions

All drug doses listed in this table are adult doses and not children’s doses.

Table 14.1 Common drugs used for ear conditions

Dose

Common side effects

Betamethasone drops

2–3 drops every 2–3 hours, reduce frequency when relief obtained

Few recorded

Steroid drops combined with antibacterial, e.g. Gentisone HC®, Predsol N®, and Sofradex®

2–4 drops 3–4 times daily (NB Gentisone HC is administered 3–4 times daily and at night)

Local sensitivity reactions

Cerumol® drops

Apply a generous amount (normally 5 drops) while patient lying down with affected ear uppermost for 5–10 minutes

Possible irritation

Betahistine tablets

Initially 16 mg 3 times daily preferably with food, maintenance 24–48 mg daily

Gastrointestinal disturbances, headache, rashes, and pruritus

Common drugs used for eye conditions

All drug doses listed in this table are adult doses and not children’s doses.

Table 14.2 Common drugs used for eye conditions

Antibiotics

Dose

Common side effects

Chloramphenicol 0.5% drops

Apply 1 drop every 2 hours; reduce frequency as infection is controlled and continue for further 48 hours after healing

Transient stinging

Anti-inflammatory

Dose

Common side effects

Betamethasone

Apply 1 drop every 1–2 hours until inflammation is controlled, then reduce frequency

Potential ‘steroid glaucoma’ and/or ‘steroid cataract’ in susceptible patients; thinning of the cornea and sclera

Mydriatics/cycloplegics

Dose

Common side effects

Cyclopentolate drops

0.5% and 1%

Single or normally short-term use

Transient stinging, raised intra-ocular pressure; on prolonged administration local irritation, hyperaemia, oedema, and conjunctivitis may occur; toxic systemic reaction to cyclopentolate (and atropine eye drops) may occur in the very young and very old

Tropicamide drops

0.5% and 1%

Treatment of glaucoma

Dose

Common side effects

Beta blocker drops, e.g. betaxolol and timolol

Apply twice daily

NB Systemic absorption may occur, therefore see side effect profile ( 							Nursing patients with sensory system problems (eyes, ears, nose, and throat) Table 7.1 Common drugs used for cardiovascular disorders: Beta blocker drugs, p.[link]); other side effects include ocular stinging, burning, pain, itching, dry eyes, erythema and allergic reactions

Prostaglandin analogue drops, e.g. latanoprost

Apply once daily in the evening

Brown pigmentation, blepharitis, ocular irritation and pain, darkening/thickening/lengthening of eyelashes, conjunctival hyperaemia, transient punctate epithelial erosion, skin rash

Dipivefrine drops

Apply twice daily

Severe smarting and redness of the eye (NB Use with caution in patients with hypertension and heart disease)

Acetazolamide tablets/capsules

0.25–1 g daily in divided doses

Nausea, vomiting, diarrhoea, loss of appetite, taste disturbance, paraesthesia, flushing, headache, dizziness, fatigue, irritability, depression, thirst, reduced libido, metabolic acidosis and electrolyte disturbances on long-term therapy

Pilocarpine drops

Apply up to 4 times a day depending on preparation used

Ciliary spasm leading to headache and browache which may be more severe in initial 2–4 weeks of therapy; ocular side effects include burning, itching, blurred vision, conjunctival vascular congestion, vitreous haemorrhage, papillary block and lens changes with chronic use

Tear deficiency

Dose

Common side effects

Hypromellose drops

Use hourly or as required

Few recorded

Common drugs used for nose, throat, and mouth conditions

All drug doses listed in this table are adult doses and not children’s doses.

Table 14.3 Common drugs used for nose, throat, and mouth conditions

Dose

Common side effects

Topical nasal decongestants

Ephedrine: 1–2 drops in each nostril up to 3–4 times daily when required

Xylometazoline: 2–3 drops into each nostril 2–3 times daily when required; maximum duration 7 days

Local irritation, nausea, headache; after excessive use – tolerance with diminished effect, rebound congestion, and possibly cardiac effects

Pseudoephedrine

60 mg 4 times daily

Tachycardia, anxiety, restlessness, insomnia

Beclometasone

100 mcg (2 sprays) into each nostril twice a day; when symptoms controlled, 50 mcg (1 spray) 3–4 times daily; maximum 400 mcg (8 sprays) daily; when symptoms controlled, 1 spray into each nostril twice daily

Dryness, irritation of nose and throat, epistaxis; nasal septal perforation can occur usually following nasal surgery

Mupirocin nasal ointment

NB Reserve for eradication of nasal carriage of MRSA

Apply 2–3 times daily to inner surface of each nostril for 5 days

Few recorded

Chlorhexidine and neomycin cream

Eradication of nasal staphylococci: apply to nostrils 4 times daily for 10 days

Prevention of nasal carriage of staphylococci: apply to nostrils twice a day

Few recorded

Hexetidine, mouthwash/gargle

15 mL undiluted 2–3 times daily

Occasional numbness or stinging

Nystatin suspension

100,000 units held in mouth 4 times daily after food for 7 days (continue for 2 days after lesions resolved)

Oral irritation and sensitization; nausea also reported