This chapter reviews three skills and two procedural guidelines: eye care for comatose patients, taking care of contact lenses, eye irrigation, ear irrigation, and care of hearing aids.
Artificial sensory aids can restore some vision and hearing loss. However, these aids must fit and work properly for patients to function optimally in their environments.
When caring for patients who use aids to assist with visual or auditory loss it is important that you and the health care team, along with the patient and their family, understand how to clean and care for these aids. Breakage or loss of the aid is expensive.
When a patient is without visual or hearing devices communication is altered, the patient is isolated socially, and there is an increase in patient dependence, it interferes with communication, and increases patient dependence.
When a patient has auditory impairments, the increased background noise in an unfamiliar environment often makes a patient more anxious and decreases his or her ability to adjust to new surroundings.
Understand the cause of a person’s sensory loss and then determine the patient’s own perception of the reason for the loss.
[Ask students: what kind of effect does a hospital have on hearing or vision impaired patients? Discuss: hospitals, rehabilitation centers, and skilled nursing facilities are inherently noisy places. They have many hard surfaces to deflect sound, as well as medical equipment and televisions that produce sound. The constant need to communicate surrounds the patient with voices. For the hearing impaired, all of this noise makes hearing even more difficult. For the vision impaired, it becomes difficult to rely on hearing to orient the patient to new surroundings.]
Dual sensory impairment (DSI) can affect a patient’s success in using assistive devices and rehabilitation services, preventing the patient from progressing to a higher level of independent function.
Although the evidence is not conclusive, some literature suggests that DSI is more debilitating than a single sensory impairment.
Older adults may not actually perceive their hearing loss because initially it is mild; however, as it progresses, they usually avoid or delay hearing evaluation.
Identify patients at risk for hearing impairments: Male over age 65, male or female over age 75, resident in nursing agency, existing visual impairment, chronic ear infection, prolonged exposure to loud noises, and use of ototoxic medication.
[Ask students: what are some examples of visual impairments? Discuss: reduced visual acuity, visual field loss, contrast sensitivity reduction, glare disability.]
Involving patients with DSI in volunteer work has been shown to result in fewer depressive symptoms compared to people without sensory loss who volunteer.
Patients with DSI will have unique communication needs that require a thorough assessment.
Correct answer: B
Rationale: Because of the comfort with silence, one can easily mistake a patient’s silence for a measure of comfort and never correctly assess what a patient is able to hear, or whether the information is heard correctly. At times the nurse will use touch to get the attention of a patient with decreased hearing.
[Ask students: how does sensory alteration place a patient at risk for injury? Discuss: ability to maneuver through home, climb stairs, respond to alarms.]
Select interventions based on the type of sensory loss, patient preference, and patient safety.
Educate family and friends about the best way to help patient adapt to sensory loss.
This increases the risk of improper administration of medications in the home setting. In addition, certain eye conditions such as cataracts and macular degeneration cause a patient difficulty when adjusting to changes in contrast and brightness.
[Discuss ways to ensure that the patient understands about care or an upcoming procedure.]
When patients are heavily sedated or in a coma, tear production is reduced; as a result, normal lubrication of the eye surface is decreased.
Critically ill patients are often on mechanical ventilators and are heavily sedated, which alters normal blinking reflex.
The blinking reflex flushes debris out of the eye. When patients are heavily sedated or in a coma, tear production is reduced; as a result the normal lubrication of the eye surface is decreased.
Tears maintain a moist environment, lubricate the eyes, wash away foreign material and cell debris, prevent organisms from adhering to the ocular surface, and transport oxygen to the outer eye surface.
When a patient’s normal protective eye mechanisms are not effective, the nurse is responsible for providing this care.
[Ask students: what kind of damage can occur to the cornea as a result of losing these protective mechanisms? Discuss: corneal scarring, premature cataract formation, and vision changes.]
Simple eye hygiene measures such as moisture chambers, lubrication, and corneal surface protection are the best interventions to decrease the risk for or prevent damage to the cornea.
It is the nurse’s responsibility to assess a patient’s eyes and administer the sterile lubricant.
[Ask students: what does it mean that nursing assistive personnel (NAP) can adapt the skill for specific patients? Discuss: for example, using skin-sensitive tape to affix eye pads for patients with sensitive skin.]
Today rigid gas permeable (RGP) and soft contact lens are available. RGP lens are smaller than the soft lens and initial awareness of the lens is present, but total comfort usually occurs within a couple of weeks.
Daily disposable soft contact lenses are made of a flexible hydrogel plastic and cover the entire cornea and a small rim of the sclera.
As contact lenses are worn, secretions and foreign matter adhere to the lens surface.
[Ask students: why is it important to determine whether patients wear contact lenses? Discuss: if a seriously ill patient is wearing contact lenses and this fact goes undetected, severe corneal injury can result.]
[Ask students: what kinds of things should you know about a patient’s contact lenses and routine? Discuss: specific types of contact lenses, including cleaning solutions and routine, wear schedule, storage, and replacement schedule.]
Correct answer: C
Rationale: Gentle pressure on the eyelid may help to center the lens on the cornea. The nurse can also ask the patient to blink a few times.
If the person wears contact lens and they did not wash out with the irrigation, have the person try to remove the lens.
A chemical injury to the eye is considered an emergency and requires flushing the eye with copious amounts of irrigation fluid.
Often cool tap water is recommended for emergency eye flushing because it is effective, immediately available for first aid, and initially helps to dilute the concentration of the chemical.
The goal in treating ocular chemical injury is to prevent or reduce visual loss caused by the burn.
[Discuss why this task cannot be delegated to NAP, when care of a prosthetic eye can be delegated.]
[MAR = medication administration record.]
Teaching
Help patient identify potential hazards at home and work and take steps to prevent accidents such as use of safety goggles while working with dust or chemicals.
Review first aid procedures for eye emergencies with patient and/or caregiver.
Instruct patient to not press or rub an injured eye.
Instruct patient to consult with personal eye care physician before reinserting contact lens.
[Ask students: why is it sometimes necessary to restrain a child? Discuss: the child may rub the eye, causing additional damage, or the child may not want to hold still for irrigation, delaying treatment and resulting in additional damage.]
[Ask students: how can irrigation lead to rupture of the tympanic membrane? Discuss: rupture of the tympanic membrane can occur by forcing an irrigant into the canal under pressure.]
Warming the irrigation solution to body temperature may prevent vertigo or nausea in patients during ear irrigation.
The greatest danger during ear irrigation is trauma to the tympanic membrane by forcing irrigant into the canal under pressure.
Damage to the external auditory meatus may occur by scratching the lining of the canal if a patient suddenly moves or if there is inadequate control of the irrigating syringe.
Ear emergencies can include the presence of foreign bodies, insect bites, or percussion injuries. A patient can also sustain damage from inside the ear, which includes blood and drainage.
If a head or neck injury is suspected, immobilize the patient.
Do not irrigate the ear if:
You suspect a head or neck injury; cover the outside of the ear with a sterile dressing, if one is available, and get medical help immediately.
Vegetable matter or an insect is present in the canal.
The tympanic membrane is ruptured.
The patient has otitis externa, myringotomy tubes, or a mastoid cavity.
[Ask students: what are some potential side effects of ear irrigation? Discuss: pain, drainage, dizziness.]
[MAR = medication administration record.]
Teaching
Instruct patient that cerumen has an antibacterial effect that maintains an acid pH in the auditory canal.
Instruct patients to clean ears daily with a washcloth, soap, and warm water.
Warn patients against placing objects (including cotton swabs) in ears.
Pediatric
When cleaning the ear of a small child, be certain that child’s head is immobilized to prevent puncturing eardrum. It may be necessary to have child’s parent or staff participate.
[Ask students: a patient asks if it is okay to clean his ears with a cotton swab—how would you answer? Discuss: warn patients against placing any object, including cotton swabs, in the ears.]
[Discuss the procedure for home instillation of mineral oil.]
Correct answer: A
Rationale: Always attempt to remove foreign objects in the ear by first simply straightening the ear canal. If vegetable matter (such as a dried bean or pea) is occluded in the canal, do not perform irrigation. The material can swell on contact with water, causing further damage to the canal.
Hearing loss is the most common sensory deficit in older adults.
Only one out of five people who actually need a hearing aid wear one. Those who do not wear a hearing aid often say that they do not wear a hearing aid because of the quality of sound that the aid produces.
Initially a person with hearing loss may deny the condition or feel that there is a stigma attached to the actual hearing loss or the need for a hearing aid.
Any hearing loss has social implications, and the person may not engage in social activities.
In addition in social situation people with a hearing aid often feel that once their aid is observed conversation occurs “around them.”
Not only do people with hearing loss have difficulty hearing car horns and emergency sirens; they also have difficulty understanding patient education and, as a result, may not safely manage their symptoms or therapies.
The role of a hearing professional is to determine what type of aid the patient needs and how to establish the best auditory settings for individual patients.
[Review Table 19-1 with students: Types of Hearing Aids]
All hearing aids have four basic components:
A microphone, which receives and converts sound into electrical signals
An amplifier, which increases the strength of the electrical signal
A receiver, which converts the strengthened signal back into sound
A power source (batteries)
The two main types of electronic hearing aids are analog and digital
Analog technology converts sound waves into electrical waves, which are amplified
Digital technology converts sound waves into numerical codes. Digital aids give the audiologist more flexibility in fine tuning the aid to meet the patient’s needs
Be sure that a patient can see your face; speak slowly in a normal tone; and rephrase rather than repeat if he or she cannot understand you
Remember that a patient is unable to hear alerts such as fire alarms and overhead announcements
[Review options for communication when the aid is not in use.]
[What could a sudden decrease in hearing acuity reflect?]
Teaching
[Ask students: why is it important to put away hearing aids and batteries securely when they are not in use? Discuss: batteries are toxic if swallowed; keep them away from pets and children. Dogs in particular and cats are attracted to the smell of used hearing aids. Advise patients to protect the hearing aids and their pets by properly storing aids out of reach.]
Patients should insert the aid after their hair is dried and any hair spray has been applied. Heat from the hair dryer or perfumes and hair spray can damage the aid.
Encourage patients to identify helpful communication tips and teach them to others. Many patients find facial cues informative. Speakers must:
Face patient, stay within 3 to 4 feet away, and keep hands away from the mouth.
Get the patient’s attention before speaking.
Rephrase rather than repeat when the patient cannot understand.
Reduce background noise or move to a quiet area.
Pediatric
Children are more often fitted with behind-the-ear (BTE) hearing aids because the ear canal is still growing.
The aid is made less conspicuous with hair styling or becomes a statement of fashion and personality with a brightly colored or transparent case.
Children need help to prevent acoustic feedback (whistling), which they are unable to hear. This is usually eliminated by removing and reinserting the device and making sure that no hair is caught between the earmold and the canal, or by lowering the volume of the device.
Gerontological
[Ask students: what should the hearing aid be protected from? Discuss: water, alcohol, hair spray or cologne, perspiration, rain, and snow, and to avoid exposing the hearing aid to extremes of temperature. Encourage the patient to store hearing aids and batteries with desiccant or in an electronic dryer to prolong life, minimize repairs, and preserve batteries.]
The small size of some hearing aids may make them difficult to manipulate, particularly for individuals with decreased dexterity or visual acuity. Consult an audiologist to identify an aid that accommodates a patient’s particular need.
Home care
Determine presence and willingness of caregiver to perform necessary care of hearing aid
Assess patient’s home and determine need for special precautions given patient’s limited hearing.