nursesrevision@gmail.com

Care of a child under going eye surgery (1)

Care of a child under going eye surgery

EYE CARE

Eye care is characterized as the special attention given to the eyes to prevent complications.

Natural Cleansing:

  • The production of tears and the blinking mechanism provide a natural cleansing process for the eyes (Harrison, 2006). When this process is interrupted, the eyes may need to be artificially cleansed to remove debris, prevent dryness, and ensure eyelid closure (Dawson, 2005).

Eye Cleansing:

  • Eye cleansing can be performed alone or with eye swabbing, instilling eye medication, and applying eye padding/dressing/shield.

Indications for Eye Care

  • Children Undergoing Eye Surgery: Pre-operative and post-operative eye care is important to ensure the eye is clean, free from infection, and well-prepared for surgery. This care includes instilling prescribed eye drops, maintaining proper hygiene, and following specific instructions from the ophthalmologist.
  • Children Whose Eyes Cannot Close Properly: Hydrocephalus, cerebral palsy, facial nerve palsy, and other conditions affecting eyelid closure,, where eyelid function may be compromised, maintaining eye moisture and cleanliness is essential to prevent corneal damage and infection.
  • Unconscious, Sedated, or Muscle-Relaxed Children: These children cannot blink or close their eyes effectively, making them prone to dryness and exposure to keratitis. Regular eye care, including lubrication and protective measures, is necessary to prevent complications.
  • Presence of Infection (e.g., Conjunctivitis/Neonatal Conjunctivitis): Eye infections require careful cleansing and medication administration to control and eradicate the infection. This prevents the spread of infection and promotes faster healing.
  • Infants with Non-Infected Sticky Eye Due to Underlying Causes (e.g., Blocked Tear Ducts): Conditions like blocked tear ducts can cause sticky discharge. Regular eye cleaning helps keep the eye clear and reduces the risk of secondary infections.
  • Immunosuppressed Children: These children are more susceptible to infections due to their weakened immune systems. Regular and prompt eye care helps prevent opportunistic infections and maintain eye health.
  • Trauma: Eye injuries require prompt and careful cleaning to remove debris, prevent infection, and manage pain. Eye care post-trauma is crucial for recovery and to avoid further damage.
  • Chronic Eye Conditions (e.g.,Dry Eye Syndrome): Conditions causing chronic dryness need regular lubrication to maintain comfort and prevent damage to the cornea and conjunctiva.
  • Post-Chemotherapy/Radiation Therapy: Children undergoing cancer treatments may experience eye issues due to the side effects of therapy. Regular eye care can mitigate symptoms like dryness and irritation.
  • Congenital Eye Disorders (e.g., Ptosis, Congenital Glaucoma): Children with congenital eye disorders may need regular eye care to manage symptoms, prevent complications, and support overall eye health.
  • Post-Cataract Surgery: After cataract surgery, careful eye care is necessary to ensure proper healing, prevent infection, and manage any postoperative complications.
  • Severe Allergies: Children with severe allergies may experience frequent eye irritation and discharge, necessitating regular cleaning and medication application.
  • Exposure to Environmental Irritants: Children exposed to smoke, dust, or chemicals need regular eye cleaning to remove irritants and prevent damage.
Purpose of Performing Eye Care (1)

Purpose of Performing Eye Care

  • Maintain Eye Cleanliness: Regular eye care helps keep the eyes clean, promoting comfort for the patient and reducing the risk of cross-infection, particularly in clinical settings.
  • Prevent Eye Dryness: Various methods are employed to keep the eyes moist and comfortable. These include:
  1. Methylcellulose Drops: Used for general lubrication.
  2. Ointments: Provide longer-lasting moisture.
  3. General Lubricants: Help maintain moisture balance.
  4. Polyacrylamide Hydrogel Dressings: Effective for unconscious, sedated, or paralyzed children as they moisten and lubricate the eye area while maintaining eyelid closure.
  5. Hypromellose Drops (Artificial Tears): Used to supplement natural tears and prevent dryness.
  • Ensure Eyelid Closure: Using polyacrylamide hydrogel dressings like Geliperm® helps keep the eyelids closed, which is crucial for preventing exposure to keratitis in patients who cannot close their eyes naturally.
  • Treat Existing Eye Infections: Proper eye care is essential for treating infections, involving cleaning the eye and administering appropriate medications to eradicate the infection and prevent its spread.
  • Prepare for Medication Administration: Ensuring the eye is clean and free from debris before administering medications enhances the effectiveness of the treatment and reduces the risk of complications.
  • Protect the Eye During Phototherapy: When using phototherapy light lamps, especially in newborns with jaundice, eye care measures are taken to protect the retina from potential damage caused by the light exposure.
  • Support Healing Post-Surgery: After eye surgeries such as cataract removal, meticulous eye care supports the healing process, reduces the risk of infection, and helps manage post-operative discomfort.
  • Manage Allergic Reactions: In cases of severe allergies, eye care involves cleaning and administering anti-allergy medications to reduce irritation and prevent secondary infections.
  • Facilitate Proper Drainage: For conditions like blocked tear ducts, regular eye care helps in facilitating drainage and reducing discomfort and infection risk.
  • Prevent Damage in Systemic Conditions: In children with systemic conditions like diabetes, regular eye care is vital to monitor and manage potential complications, thus preserving eye health.
  • Educate Caregivers: Eye care is a tool for educating caregivers on proper eye care techniques, signs of complications, and the importance of maintaining eye hygiene ensures consistent and effective care for the child.

Purpose of Eye Medications:

Topical medication is the preferred route for treating eye diseases. Eye medications are delivered to:

  • Treat infections.
  • Provide intraocular treatment for diseases such as glaucoma.
  • Prepare for and recover from surgical procedures.
  • Dilate pupils for eye examinations and/or refraction.
  • Provide lubrication.
Care of the Child Undergoing Eye Surgery:

Care of the Child Undergoing Eye Surgery:

The care involves pre-operative, intra-operative, and post-operative care.

Pre-operative Care:

Common conditions requiring surgical intervention include trauma, Cataracts, Foreign body eye, Congenital malformations, Glaucoma, Eye injuries, Astigmatism or strabismus, Sagging of the upper eyelid (ptosis) and detached retina. The ophthalmologist will determine the treatment and procedure, ranging from a simple incision to total removal of the eyeball (enucleation).

  • Admission: The child will be admitted to a warm and clean bed in the pediatric surgical ward. The bed will have enough light to ensure a comfortable environment for the child and will be free from environmental dust to minimize the risk of infection.
  • History taking: Take a detailed history of the child’s medical background, including any previous surgeries, allergies, or medical conditions, also inquire about any medications the child is currently taking.
  • Physical examination. A thorough physical examination will be conducted and will assess the child’s overall health and identify any potential risks or concerns. The physical examination will include checking vital signs such as heart rate, blood pressure, and temperature and the child’s eyes will be examined to evaluate the specific condition requiring surgery and to ensure there are no additional eye health issues.
  • Observation: Vital signs (temperature, respiration, pulse, blood pressure). Observation of the affected eye.
  • Investigations: History taking from the child and parent, Physical examination of the eye, tests like Visual acuity test, Visual field test and Tonometry test for fluid pressure inside the eye (evaluates for glaucoma) are ordered and done.
  • Physical Orientation: Thorough orientation to the hospital environment to help the patient post-operatively, especially if vision is impaired. Assist older children to learn details of their room (location of furniture, doors, windows, etc.). Familiarize the patient with voices and daily sounds.
  • Education: Thorough education about post-operative care and restrictions. Keep the head still, avoid reading, showers, shampooing, tub baths, bending over, lifting heavy objects, and sleeping on the operative side.
  • Explaining the Diagnosis and the Need for Surgery: Communicate with the patient, explaining the diagnosis and the reasons for the recommended surgery. This helps the patient understand the importance of the procedure and alleviates any concerns or fears they may have.
  • Reassurance and Counseling: It is important to provide emotional support and reassurance to the patient, addressing any anxieties or fears they may have about the upcoming surgery. Counseling may also be provided to help the patient cope with the stress associated with the procedure.
  • Booking and Scheduling the Operation: The date and time for the surgery are scheduled, taking into account the patient’s availability and the surgical team’s availability. In some cases, surgeries may be booked several months in advance, and the patient should be informed about what to do in case of any problems or changes before the scheduled date.
  • One Week Before Surgery: Preoperative tests and assessments may be conducted, such as blood tests, imaging studies, and specific examinations related to the surgical procedure. The patient may also be instructed to take certain medications or eye drops as prescribed.
  • A Day Before Surgery: In some cases, the patient may be required to be temporarily admitted to the hospital the day before the surgery. During this time, the patient’s feeding and hygiene needs are addressed, and a detailed history and physical examination, including ophthalmological tests, are performed. The patient is also informed about the personal requirements and procedure-related instructions.
  • Day of Operation: The patient is required to sign a consent form, indicating their agreement for the operation. Depending on the anesthesiologist’s instructions, the patient may need to be nil per os (NPO), refraining from eating or drinking for at least 8 hours prior to surgery. Reassurance, hygiene measures, removal of jewelry, and administration of pre-medication, if necessary, are also carried out. Hydration may be provided as instructed.
  • Rest and Sleep: Ensure rest and minimize noise and bright light.
  • Physical Preparation:
  • Bowel Prep: Bowel preparation is sometimes required before surgery to empty the bowels and prevent straining post-operation. This may involve taking a laxative or using an enema the evening before surgery.
  1. Hair Removal: Hair removal, such as shaving of eyebrows, cutting of eyelashes, and shaving of the face, should only be done on the surgeon’s order. In some cases, hair removal may be necessary to ensure a sterile surgical field. 
  2. Postoperative Bed Preparation: Depending on the type of surgery, it may be necessary to prepare a postoperative bed with side rails and sandbags for head immobilization. This is done to ensure the patient’s safety and prevent any accidental movement or injury during the recovery period.
  • Transportation to the Operating Room: When it is time for the patient to be taken to the operating room, two nurses accompany the patient. This is done to ensure the patient’s safety and provide any necessary support during the transportation process.
Post-operative Care:
  • When the nurses arrive at the theater to pick up the child after surgery, the first step is to check the child’s vital signs and obtain a detailed report from the theater staff who performed the surgery. This ensures continuity of care and that all necessary information is communicated effectively.
  • The patient is taken to the pediatric surgical ward in a post-operative bed, positioning the child face down as ordered by the surgeon. This specific positioning is important for optimal recovery and to prevent complications.

Upon arrival at the pediatric surgical ward, the following post-operative care procedures are implemented:

Initial Care and Positioning.

  • Vital Observations: Regular monitoring of vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
  • Positioning: The child is positioned in bed as prescribed, usually face down to ensure recovery and prevent complications.
  • Immobilization: If ordered, sandbags may be used to immobilize the head to prevent any unnecessary movement that could affect healing.
  • Safety Measures: If both eyes are bandaged, the side rails of the bed are kept raised to prevent falls. The call bell is placed within easy reach of the patient’s head for safety and communication.
  • Rest and sleep: The child is allowed to rest in the ward temporarily to recover from the effects of anesthesia. The bed positioning continues to be monitored to ensure it aligns with the surgeon’s instructions.

Ongoing Observations:

  • Bleeding: Continuous monitoring for any signs of bleeding from the surgical site.
  • Dressings: Regular checks to ensure dressings are secure and dry. Any signs of infection or complications are promptly addressed.

Welcoming the Child:

  • The child is gently welcomed back to the ward and from the effects of anesthesia. Comforting words and reassurance are provided to help ease any anxiety or discomfort they may feel upon waking.
  • Apply non-sterile gloves (to remove old eye dressing or patches/shields and discard them appropriately. If eye dressings  are difficult to remove from the eyelid / lashes, apply gauze moistened with 0.9%w/v NaCl solution to the eye dressing.
  • Assess the general condition of each eye and surrounding tissue before proceeding for:-
  1. Redness
  2. Swelling
  3. Abrasions
  4. Irritation (itching, stinging, burning)
  5. Discharge (colour, odour, volume)
  6. Eyelid position (partial/full closure, blink)
  7. If cooperative, ask the child to look upwards, or if uncooperative gently hold the child with parental assistance and then gently pull the lower lid downwards to part the eyelid.
  8. If there is evidence of any encrustation on the eyelids and lashes, dampen sterile gauze with 0.9%w/v NaCl solution and apply to the eye.
  9. If there is any discharge, perform an eye swab before proceeding with eye cleansing

Performing Eye Swabbing:

  • Use a sterile cotton wool swab to roll over the conjunctival sac inside the lower eyelid.
  • Place the swab in the transport medium and transport immediately to the laboratory.
  • For suspected Chlamydia Infection, perform the eye swab after eye cleansing.

Performing Eye Cleansing:

  • Use 0.9% NaCl or sterile water in a sterile gallipot.
  • Moisten sterile gauze with the solution.
  • Wipe the eye from the inside aspect to the outside aspect, using a new gauze square for each stroke.
  • Clean the non-infected eye first.
  • Decontaminate hands again.

Instilling Eye Medication:

  • Cleanse the eye(s) before instilling medication.
  • Check the child’s identification band against the medication prescription chart.
  • Adolescents over 16 may consent to the procedure, but supervision is required if the medication affects vision.
  • Use new medication containers post-surgery.
  • Position a hand gently on the forehead while holding the medication container.
  • Place a tissue/non-sterile gauze swab under the lower eyelid and gently pull down the lower eyelid.

Applying Eye Padding/Dressing(s)/Shields:

  • Eye Padding: Apply gauze over the closed eyelid and secure it with tape.
  • Eye Dressings: Use polyacrylamide hydrogel dressings (Geliperm®) to cover the closed eyelid.
  • Eye Shield: Apply a clear shield over the affected eye and secure it with clear tape.

Precautions:

  • Secure eye dressings with an eye shield or reinforce loose tape.
  • Restrain the arms of children and disoriented patients as appropriate.
  • Constantly watch sleeping patients to maintain proper positioning.
  • Avoid jarring the bed to prevent startling the patient.
  • Monitor for depression or suicidal tendencies in newly blinded patients.

  • Check the physician’s orders before giving anything by mouth to avoid nausea and vomiting.

Approaching the Patient:

  • Always speak to the patient upon entering their area and before touching them.
  • Explain each procedure or activity fully.
  • Reinforce orientation to surroundings.
  • Inform the patient when leaving their area.

Diversional Activity:

  • Provide non-fatiguing activities if eyes are not bandaged.
  • Encourage visitors to chat or read to the patient.
  • Use a radio for entertainment and to keep the patient informed.

Nursing Care of the Patient with Vision Loss:

  • Physical Orientation: Describe the room and its contents in detail and lead the patient around the room.
  • Precautions: Inform the patient about any changes in the room, keep doors fully open or closed, maintain the placement of toilet articles, and remove hazardous items.
  • Assisting the Patient: Address the patient by name, inform them when leaving, and allow them to place their hand on your arm or shoulder when walking.
  • Encourage Independence: Encourage the patient to be self-sufficient.
Complications of eye surgery

Complications of eye surgery;

  • Infections such as Endophthalmitis: A serious infection inside the eye. This can lead to vision loss if not treated promptly.
  • Fluid and Swelling like Cystoid Macular Edema: Swelling and fluid build-up in the macula, the central part of the retina responsible for sharp, central vision. This can cause blurred vision.
  • Corneal Edema: Swelling of the cornea, the clear outer layer of the eye. This can cause blurry vision and discomfort.
  • Bleeding (Hyphema): Bleeding in the front chamber of the eye, the space between the cornea and the iris. This can cause pain, redness, and blurry vision.
  • Tissue Damage such as Capsule Rupture: The capsule surrounding the lens may rupture during surgery, leading to loss of vitreous gel, the clear jelly-like substance that fills the eye. This can cause blurry vision and other complications.
  • Retinal Detachment: The retina, the light-sensitive tissue at the back of the eye, can become detached from the underlying choroid. This can lead to permanent vision loss.
  • Cataract Formation: While rare, eye surgery can sometimes trigger the development of a new cataract.
  • Glaucoma: Eye surgery can, in some cases, increase the pressure inside the eye, potentially leading to glaucoma.
  • Dry Eye Disease: Dry eye can become worse or develop after eye surgery due to changes in the eye’s surface.

Care at Home After Eye Surgery

Bathing

  • Clean your eyelid edges: At least twice a day with a moist, clean face cloth, avoiding pressure on the upper eyelid.
  • Showering/Bathing: You may shower or take a tub bath and wash your hair the day after surgery.
  • Avoiding Soap/Water in Eye: Ensure no soap or water enters the eye for at least one week.
  • Eye Make-up: Do not wear eye make-up for at least one week.
  • Avoid Fibrous Materials: Do not use cotton balls or make-up remover pads near your eye or under the eye shield.

Care of Your Eye

  • Protective Eye Shield: Wear your protective eye shield when sleeping or lying down for at least one week to protect from accidental bumps or scratches.
  • Cleaning the Eye Shield: Clean it once a day with 70% isopropyl alcohol and allow it to air dry before reusing.
  • Glasses: You may wear your old glasses if needed. Vision may be better without them in the operated eye.
  • Attaching the Shield: Attach the tape to your forehead over the shield and tape it to your cheek.

Activity

  • Permissible Activities: You may watch TV, read, or go for walks if you feel up to it.
  • Saunas and Hot Tubs: Avoid these for at least one week.
  • Sleeping Position: Avoid sleeping on the operated side for at least two weeks.
  • Straining and Lifting: Avoid straining or lifting anything over 10 lbs. (4.5 kg) for at least two weeks or until your surgeon advises otherwise.
  • Swimming/Submersion: Avoid swimming or submerging your head in water for at least three weeks.
  • Strenuous Activities: Do not engage in very strenuous activities or rough contact sports for at least four weeks or until cleared by your surgeon.
  • Eye Protection: Avoid rubbing or bumping your eye for at least six weeks.
  • Sexual Activity: Resume when you feel comfortable.
  • Driving: Do not drive until your surgeon gives you the okay.

Healthy Eating

  • Diet: Resume your regular diet after surgery.
  • Avoid Constipation: Prevent constipation and forceful straining during bowel movements by increasing fluids, activity, and fiber in your diet.

Medications

  • Regular Medications: Restart all regular medications you took before surgery unless instructed otherwise by your doctor.
  • Postoperative Eye Drops: Obtain all prescriptions for postoperative eye drops and take them as directed by your surgeon.
  • Artificial Tears: You may use artificial tears like Refresh™ or Genteal™ to reduce scratchiness. Wait 30 minutes after using prescription eye drops before using artificial tears.

When to Seek Help

  • Worsening Eyesight: If your eyesight worsens.
  • Increasing Pain: If you experience increasing pain or ache in the eye.
  • Redness: If there is increasing redness.
  • Swelling: If there is swelling around the eye.
  • Discharge: If there is any discharge from the eye.
  • New Symptoms: If you notice new floaters, flashes of light, or changes in your field of vision.

How to Instill Eye Drops

  1. Wash Your Hands: Ensure your hands are clean before touching your eye drops.
  2. Tilt Your Head: Look at the ceiling from a sitting or lying position.
  3. Form a Pocket: Use one or two fingers to gently pull down your lower eyelid to form a pocket.
  4. Instill the Drop: Keeping both eyes open, gently squeeze one drop into the eye pocket. Avoid letting the bottle top touch your eye, eyelashes, fingers, or any surface.
  5. Close the Eye: Close the eye for 30 to 60 seconds to let the drops absorb.
  6. Avoid Rubbing: Do not rub your eyes after applying the drops. Gently blot the eye area with a tissue if needed.
  7. Multiple Drops: When using multiple eye drops, wait about three minutes after instilling the first medication before applying the next.

Care of a child under going eye surgery Read More »

Eye Infections in Children

Eye Infections in Children

EYE INFECTIONS

Eye infections occur when bacteria, viruses, fungi, or other microorganisms invade the tissues of the eye or its surrounding structures. 

These infections can range from mild to severe and may involve various parts of the eye, including the conjunctiva, cornea, eyelid, or internal ocular structures.

  • Conjunctivitis: Conjunctivitis, commonly known as ‘pink eye’, is a widespread infection typically caused by bacteria or viruses. It is highly contagious and often affects children in schools or other group settings where it can easily spread from child to child. It gives the eye a pink or reddish tinge.
  • Trachoma: Trachoma is a common infection in certain developing regions and is one of the leading causes of blindness in those areas. It can be spread by flies, and reinfection is a significant problem. Proper hygiene and access to treatment are crucial.
  • Endophthalmitis: Endophthalmitis is a bacterial infection that affects the inside of the eye, often due to an injury or, rarely, after eye surgery. Without immediate and powerful antibiotic treatment, it can cause blindness. A type of mold can also cause this condition, although it is rare.
  • Stye or Chalazion: These infections affect the inside of the eyelids.
  • Dacryocystitis: This is an infection of the tear ducts, leading to inflammation and blockage of the tear drainage system.
  • Corneal Ulcers: These can be caused by infections and may be associated with the use of contact lenses. Corneal ulcers are serious and can lead to severe vision loss if not treated promptly.
  • Orbital Cellulitis: This infection attacks the soft tissue around the eyelids and is a serious emergency. It requires immediate treatment to prevent the infection from spreading.
  • Keratitis: An infection or inflammation of the cornea. Can be caused by bacteria, viruses, fungi, or parasites. Symptoms: Pain, redness, blurred vision, photophobia, and corneal cloudiness.
  • Blepharitis: An infection or inflammation of the eyelid margins. Commonly caused by bacterial infection, seborrheic dermatitis, or blocked oil glands. Symptoms: Crusty eyelids, redness, swelling, burning sensation, and itching.
  • Uveitis: Inflammation of the uvea, often associated with autoimmune conditions or infections. Symptoms: Eye pain, redness, blurred vision, and photophobia.
STYE (HORDEOLUM)

STYE (HORDEOLUM)

A stye, also known as a hordeolum, is a localized infection of the hair follicle or the oil-producing (sebaceous) or sweat glands in the eyelid. 

A stye, or hordeolum, is a localized, painful bacterial infection or inflammation of the glands or hair follicles at the edge of the eyelid. 

Commonly caused by Staphylococcus aureus.

It often results from Staphylococcus aureus infection and can occur either externally (on the lid margin) or internally (within the eyelid).

Types of Stye

1. Internal Hordeolum: Affects the Meibomian glands, which are sebaceous glands located within the eyelid.

Clinical Characteristics:

  • The infection occurs deeper within the eyelid, often making it more painful and tender.
  • Swelling may involve the entire eyelid.
  • The internal stye can sometimes evolve into a chalazion if it becomes chronic and non-infectious.

2. External Hordeolum: Involves the glands of Zeis (sebaceous glands) or Moll glands (sweat glands) at the base of the eyelash follicle.

Clinical Characteristics:

  • Appears as a small, red, painful lump resembling a pimple on the edge of the eyelid.
  • Usually less painful than an internal hordeolum.
  • Often associated with localized swelling and redness around the affected area.
Causes of Stye Formation
  1. Bacterial Infection: Most commonly caused by Staphylococcus aureus.
  2. Blocked Glands: Blockage in the sebaceous glands (Meibomian, Zeis, or Moll glands) can trigger inflammation.
  3. Poor Eyelid Hygiene: Failure to remove makeup or debris from the eyelid margins.
  4. Contact Lens Misuse: Wearing lenses without proper cleaning or disinfection can introduce bacteria.
  5. Pre-existing Conditions: Conditions such as blepharitis, rosacea, or seborrheic dermatitis increase susceptibility.
  6. Immune System Deficiency: Reduced immunity can predispose individuals to bacterial infections.
Clinical Features

Early Symptoms:

  • Mild itching and discomfort in the affected area.
  • A sensation of fullness or heaviness in the eyelid.

Progressive Signs:

  • Pain: Localized tenderness and pain, especially on palpation.
  • Redness: Visible inflammation and redness at the eyelid margin or deeper within the eyelid.
  • Swelling: Puffy, swollen eyelid, which may extend to the surrounding areas.
  • Pus Formation: Formation of a yellowish, fluid-filled pustule near the edge of the eyelid.
  • Soreness: Persistent irritation and soreness over the affected site.

Advanced Symptoms:

  • Drainage of Fluid: Spontaneous rupture may release yellowish or white pus, leading to symptom relief.
  • Visual Obstruction: Swelling may partially block vision in severe cases.
Management of Stye

1. General Care

Avoid Rubbing or Touching the Eye:

  • Rubbing can introduce additional bacteria and exacerbate the infection.
  • Rationale: Prevents spreading the infection to other areas of the eyelid or eye.

Warm Compresses:

  • Apply a warm or hot compress (clean cloth dipped in warm water) for 10–15 minutes, 3–4 times a day.
  • Rationale: Encourages drainage of pus, relieves pain, and reduces swelling.

2. Medications

Antibiotic Eye Ointments:

  • Tetracycline 1% eye ointment applied 2–4 times daily until 2 days after the symptoms subside.
  • Rationale: Reduces bacterial load, speeds up healing, and prevents further spread of infection.

Analgesics:

  • Oral pain relievers like ibuprofen or paracetamol for pain relief.
  • Rationale: Helps manage discomfort and swelling.

3. Eyelash Removal

  • Removal of loose or infected eyelashes may be performed by a healthcare provider.
  • Rationale: Prevents recurrent infections by removing the source of blockage or bacterial growth.

4. Hygiene Practices

  • Clean the eyelid regularly using a sterile saline solution or lid-cleaning wipes.
  • Avoid sharing towels, makeup, or other personal items to prevent the spread of bacteria.

5. Lifestyle Modifications

  • Maintain proper hygiene when wearing and handling contact lenses.
  • Discontinue makeup use until the stye resolves.

6. Referral to a Specialist

  • In cases where the stye does not resolve or becomes recurrent, refer the patient to an ophthalmologist.
  • Persistent or worsening symptoms may require surgical drainage or further investigation.
Potential Complications of Stye
  1. Chalazion Formation: A chronic, painless lump that can form after an internal stye resolves but leaves a residual blocked gland.
  2. Preseptal Cellulitis: Infection spreading to the surrounding eyelid tissues, leading to redness, swelling, and warmth.
  3. Recurrent Styes: Especially common in individuals with underlying conditions like blepharitis or rosacea.
Prevention of Stye
  1. Good Eyelid Hygiene: Regular cleaning of the eyelid margins with gentle cleansers or baby shampoo diluted with water.
  2. Avoid Eye Contamination: Do not touch or rub the eyes with unclean hands. Avoid using expired or contaminated eye makeup products.
  3. Contact Lens Care: Follow proper cleaning, storage, and replacement practices for contact lenses.
  4. Manage Underlying Conditions: Treat chronic eyelid conditions like blepharitis or seborrheic dermatitis to prevent blockage of the glands.
  5. Boost Immune Health: Maintain a healthy diet, adequate hydration, and overall wellness to reduce susceptibility to infections.

TRACHOMA

Trachoma is a chronic infection of the outer eye caused by Chlamydia trachomatis, transmitted through direct personal contact, shared towels and cloths, and flies that have come into contact with the eyes or nose of an infected person. It is a common cause of blindness.

trachoma staging (1)
Staging of Trachoma

Stage I: Trachomatous follicles- follicular (TF). Presence of five or more follicles in the upper tarsal conjunctiva. Follicles are whitish grey or yellow elevations, paler than the surrounding conjunctiva.

Stage II: Trachomatous inflammation – intense (TI). The upper tarsal conjunctiva is red, rough, and thickened. The blood vessels, normally visible, are masked by a diffuse inflammatory infiltration or follicles.

Stage III: Trachomatous scarring (TS). Follicles disappear, leaving scars: scars are white lines, bands, or patches in the tarsal conjunctiva.

Stage IV: Trachomatous trichiasis (TT). Due to multiple scars, the margin of the eyelid turns inwards (entropion); the eyelashes rub the cornea and cause ulcerations and chronic inflammation.

Stage V: Trachomatis corneal opacity (CO). The cornea gradually loses its transparency, leading to visual impairment and blindness.

Treatment and Management of Trachoma:

Community Diagnosis: Essential to establish whether the disease is of public health importance in the community. If so, the SAFE strategy should be the appropriate approach.

The SAFE strategy stands for:

  • Surgery for trachomatous trichiasis (S): Trachomatous trichiasis is the blinding stage of trachoma where the eyelashes turn inwards and rub against the eyeball, causing constant pain and light intolerance. Surgery is performed to correct this condition and prevent further damage to the cornea.
  • Antibiotics (A): The application of antibiotics, especially the highly effective azithromycin, is a component of the SAFE strategy. Antibiotics are used to clear the infection and reduce the transmission of Chlamydia trachomatis. Mass drug administration of azithromycin is often conducted in endemic communities to treat and prevent trachoma.
  • Facial cleanliness (F): Promoting facial cleanliness is an important preventive measure to reduce the transmission of trachoma. This includes proper hygiene practices such as washing the face with clean water and soap, especially focusing on the eyes and nose, to remove discharge and prevent the spread of infection.
  • Environmental improvement (E): Improving access to water and sanitation is essential in reducing the transmission of trachoma. Inadequate access to water and sanitation facilities contributes to the spread of the disease. Environmental improvement measures aim to provide clean water, proper sanitation, and hygiene education to communities at risk

Stages I and II:

Clean eyes and face several times per day.

Antibiotic therapy: The treatment of choice is azithromycin PO:

  • Children over 6 months or over 6 kg: 20 mg/kg single dose
  • Adults: 1 g single dose

Failing the above, 1% tetracycline eye ointment: one application 2 times daily for 6 weeks

In children under 6 months or 6 kg: erythromycin PO (20 mg/kg 2 times daily for 14 days)

Stage III: No treatment

Stage IV: Surgical treatment

  • While waiting for surgery, if regular patient follow-up is possible, taping eyelashes to the eyelid is a palliative measure that can help protect the cornea. In certain cases, this may lead to permanent correction of the trichiasis within a few months.
  • The method consists of sticking the ingrowing eyelashes to the external eyelid with a thin strip of sticking plaster, making sure that the eyelid can open and close perfectly. Replace the plaster when it starts to peel off (usually once a week); continue treatment for 3 months.
  • Note: Epilation of ingrowing eyelashes is not recommended since it offers only temporary relief and re-growing eyelashes are more abrasive to the cornea.

Stage V: No treatment

Prevention:

Improved Hygiene Practices:

  • Encourage regular face and hand washing with clean water and soap.
  • Promote the use of clean towels and avoid sharing personal items like towels and washcloths.
  • Teach proper disposal of nasal and eye secretions to prevent contamination.

Access to Clean Water and Sanitation:

  • Improve access to clean water sources for drinking, washing, and sanitation purposes.
  • Ensure proper sanitation facilities, including toilets and latrines, to reduce the spread of infection.

Environmental Improvement:

  • Control fly populations by implementing fly control measures, such as proper waste management and fly traps.
  • Reduce overcrowding in households to minimize the risk of transmission.
  • Improve housing conditions to prevent the accumulation of dust and dirt.

Antibiotic Treatment:

  • Administer antibiotics, such as azithromycin, to affected individuals and communities to clear the infection.
  • Implement mass drug administration programs in endemic areas to treat and prevent trachoma.

Surgical Intervention:

  • Provide surgical treatment for advanced trachoma, known as trachomatous trichiasis, to prevent further damage to the cornea.
  • Surgery can reposition the eyelashes to prevent them from rubbing against the cornea.
OPHTHALMIA NEONATORUM

OPHTHALMIA NEONATORUM

Ophthalmia neonatorum, also known as neonatal conjunctivitis, is any eye infection in the first 28 days of life.

ophthalmia neonatorum pathophysiology

Pathophysiology:

Inflammation of the conjunctiva causes erythema, blood vessel dilation, tearing, and drainage. This reaction tends to be more serious due to reduced tear secretion, decreased immune function, decreased lysozyme activity, and the relative absence of lymphoid tissue of the conjunctiva. Neonate tears also lack immunoglobulin IgA.

Etiology:
  • Bacterial Infections: Bacterial infections are one of the major causes of septic neonatal conjunctivitis. The most common bacterial agent historically was Neisseria gonorrhoeae, which is a sexually transmitted infection. Others,
  1. Chlamydia trachomatis (most common): 5-14 days
  2. Neisseria gonorrhoeae: 3-5 days
  3. Staphylococcus aureus
  4. Pseudomonas aeruginosa
  5. Streptococcus spp. (including S. haemolyticus, S. pneumoniae)
  6. Other bacteria include Klebsiella, Proteus, Enterobacter, Serratia, and Eikenella corrodens.
  • Viral Infections: Viral infections can also cause ophthalmia neonatorum, although they are less common than bacterial infections. Viral agents that can lead to neonatal conjunctivitis include herpes simplex virus, adenovirus, and enterovirus.
  • Chlamydial Infection: Chlamydia trachomatis is a sexually transmitted infection that can be acquired by the mother and transmitted to the newborn during delivery. Babies born to women with untreated chlamydial infection have a 30-50% chance of developing ophthalmia neonatorum. Chlamydia trachomatis can also colonize the respiratory tract, leading to pneumonitis in some cases.
  • Chemical Conjunctivitis: Aseptic neonatal conjunctivitis can be caused by exposure to certain chemicals. In the past, silver nitrate solution was used for prophylaxis, but it has been replaced by erythromycin ointment or povidone iodide in many places. Chemical conjunctivitis is becoming less common due to these changes
Presentation/Clinical Manifestations of Ophthalmia Neonatorum:

The presentation varies depending on the causative agent, but common features include:

  • Eyelid swelling: Often the first sign, varying in severity from mild edema to significant swelling that may make it difficult to open the eyes.
  • Discharge: Purulent (thick, yellow-green) discharge is characteristic of bacterial infections, while chlamydial infections may present with a less purulent, watery discharge that can become purulent later.
  • Conjunctival redness (hyperemia): The conjunctiva will appear inflamed and red.
  • Photophobia (light sensitivity): The infant may cry when exposed to light.
  • Corneal involvement: In severe cases, the cornea (the transparent front part of the eye) can become cloudy or ulcerated, leading to permanent vision impairment or blindness. This is particularly true with gonococcal infections.
  • Bilateral symptoms, affecting both eyes.
  • Edema (swelling) of the eyelids, which may impede examination of the ocular surfaces.
  • Mucopurulent conjunctivitis, characterized by a watery discharge that progresses to a copious purulent discharge in the case of chlamydial infection.
  • Conjunctival edema (chemosis).
  • Conjunctival pseudomembrane in severe cases.
  • Corneal involvement, especially in cases of Neisseria gonorrhoeae infection, which can lead to corneal perforation.
  • Epithelial edema, superficial keratitis, and possible corneal ulceration.
Ophthalmia Neonatorum: Prevention and Management

Prevention: Prevention strategies target reducing the risk of infection before, during, and after birth.

1. Antenatal (During Pregnancy):

  • Regular screening for vaginal infections: Conduct regular examinations to detect vaginal discharges indicative of infections like gonorrhea and chlamydia.
  • Treatment of vaginal infections: Ensure prompt and appropriate treatment of any identified vaginal infections in pregnant women using appropriate antibiotics.
  • Management of high-risk pregnancies: Address conditions that may increase the risk of premature labor or prolonged rupture of membranes.
  • Prevention and management of anemia: Address maternal anemia, as it can weaken the immune system and increase the risk of infection.
  • Health education: Educate mothers on the importance of hygiene, including handwashing, perineal cleanliness, and avoidance of touching the eyes unnecessarily.

2. Intrapartum (During Labor):

  • Sterile technique: Maintain strict sterile techniques during labor and delivery. All personnel should practice thorough hand hygiene.
  • Avoid unnecessary eye swabbing: Avoid routine swabbing of the baby’s eyes during delivery unless absolutely necessary, as this can introduce infection. If swabbing is deemed necessary (e.g., for assessment), use separate sterile swabs for each eye, cleaning from the inner canthus outward.
  • Isolation of infected mothers: Isolate mothers with purulent vaginal discharge to prevent transmission.
  • Prophylactic antibiotics for prolonged rupture of membranes: Consider prophylactic antibiotics for mothers with prolonged rupture of membranes (PROM) exceeding 12 hours to reduce the risk of neonatal infection.

3. Postnatal (After Birth):

  • Hand hygiene: Healthcare providers should perform thorough handwashing before and after handling newborns.
  • Eye cleaning: Cleanse the baby’s eyes with sterile water or half-strength saline solution using a separate sterile cotton swab for each eye, cleaning from the inner to the outer canthus. Discard swabs after use.
  • Avoid contact with birth fluids: Prevent the baby’s face from coming into contact with amniotic fluid.
  • Educate mothers: Instruct mothers on proper hand hygiene before handling the baby and avoid touching the baby’s eyes.
  • Prophylactic eye drops (during epidemics): In areas experiencing outbreaks of ophthalmia neonatorum, consider prophylactic eye drops (e.g., 1% silver nitrate or 10% sulfacetamide) immediately after birth. This practice is debated and requires careful consideration of potential side effects and local guidelines.
Management of Ophthalmia neonatorum:

Aims of Management:

The primary aims of management are to:

  1. Eradicate the infection.
  2. Prevent corneal damage and scarring.
  3. Preserve vision.
  4. Prevent transmission to others (e.g., other family members).

Management in a Maternity Centre (Limited to Mild Cases ONLY – Referral is usually necessary):

  • Admission and Isolation: Admit the baby and isolate them to prevent infection spread. Position the baby on its side with the affected eye downward. Use mosquito nets to protect the baby from flies. Separate and disinfect all used materials before sending them to the laundry.
  • Eye Cleaning: Cleanse the eyes with normal saline or cooled boiled water using a separate sterile swab for each eye.
  • Topical Antibiotics: Apply antibiotic eye ointment (e.g., tetracycline or erythromycin) to both eyes. If ointments are unavailable, consider using diluted crystalline penicillin (see dosage instructions below).

Dosage of Diluted Crystalline Penicillin (If Ointments Unavailable – ONLY under direct medical supervision, and ideally as a temporary measure before hospital transfer):

  1. 100,000 IU vial: Dilute with 4 ml sterile water. Use 5 drops in each eye every 5 minutes for 6 times, then 5 drops every 10 minutes for 6 times, then 5 drops every 30 minutes for 6 times, then 5 drops every hour for 3 days.
  2. 500,000 IU vial: Dilute with 20 ml sterile water. Adjust dosage proportionately.
  • Systemic Antibiotics (with strong caution, only when referral is significantly delayed and under medical supervision): Consider intramuscular crystalline penicillin 50,000 units/kg body weight every 12 hours for 7 days. This should be a last resort and is only acceptable if hospital transfer is delayed and a qualified medical professional has made the decision and is monitoring the infant’s response.
  • Referral: Refer the patient to a hospital for definitive diagnosis (gonorrhea testing, culture and sensitivity) and treatment as soon as possible.

Referral: Refer all suspected cases of ophthalmia neonatorum, especially those with purulent discharge or corneal involvement, to a hospital.

  • Assessment and Referral: Thoroughly assess the infant’s eyes. Any infant with suspected ophthalmia neonatorum, especially with purulent discharge or corneal involvement, requires immediate referral to a hospital with ophthalmology services. Do not attempt to manage significant cases in a maternity centre.
  • Initial Cleaning (before referral): Gently cleanse the eyes with sterile saline or water to remove excess discharge. Use a separate cotton swab for each eye.

Management in Hospital:

  • Diagnostic Testing: The physician will order an eye swab for culture and sensitivity to identify the causative organism.
  • Eye Cleaning: Continue meticulous eye cleaning as previously described.
  • Antibiotic Treatment: The physician will prescribe appropriate systemic and topical antibiotics based on the culture results. This may include intravenous antibiotics for severe infections. Penicillin may be used in gonococcal infections, as may other antibiotics like cefotaxime or ceftriaxone.
  • Topical Antibiotic Ointments: Use Neomycin or tetracycline eye ointment to prevent eyelid adhesion.

Medical Management: Purulent discharge in the eyes of the newborn baby

→ Take history and examine

1. Rx for the baby:

  • Always wear gloves.
  • Cover the inflamed eye with gauze before opening for your protection.
  • Clean the eye with saline or water.
  • Apply tetracycline eye ointment hourly for 24 hours, then 8-hourly for 10 days.

PLUS:

  • Ceftriaxone 125 mg IM stat.
  • OR Erythromycin syrup 15 mg/kg body weight 6 hourly x 2/52.

2. Rx for the mother:

  • Ceftriaxone 250 mg IM stat.
  • PLUS: Erythromycin 500 mg for 7 days.

3. Rx for partners:

  • Ciprofloxacin 500 mg stat.
  • Septrin 5 tablets BD x3/7.

PLUS:

  • Doxycycline 100 mg BD x7/7.
  • OR Tetracycline 500 mg 6×7/7.

Educate on compliance:

  • Schedule for a return visit.
  • Provide mother and partner with condoms and counsel on risk reduction.

Incase of specific causative organisms;

Gonococcal Ophthalmia Neonatorum: 

  • The infant should be isolated for the first 24 hours of treatment. 
  • Eyes are irrigated every 1-2 hours with sterile isotonic saline until the discharge clears. 
  • For culture-positive cases or severe infections, systemic antibiotic therapy is indicated. Ceftriaxone (25-50 mg/kg IV or IM) or cefotaxime (100 mg/kg IM or IV) is usually administered as a single dose for localized infection; a 7-day course is recommended for disseminated infection.

Chlamydial Ophthalmia Neonatorum: 

  • Oral erythromycin suspension (40 mg/kg/day divided into four doses) is administered for 14 days. 
  • Topical treatment alone is insufficient; systemic therapy is essential to prevent systemic spread.

Herpes Simplex Ophthalmia Neonatorum: 

  • The infant requires isolation. Systemic acyclovir (20 mg/kg every 8 hours IV) for two weeks is the standard treatment. 
  • Topical therapy with 3% vidarabine or 0.1% iododeoxyuridine ointment (five times daily for 10 days) may be added. 
  • Severe cases necessitate immediate ophthalmological consultation.

Nursing Care (Maternity Centre and Hospital):

  • General hygiene: Maintain meticulous hygiene, including handwashing, clean linens, and a clean environment.
  • Eye care: Continue frequent eye cleaning as previously described.
  • Comfort measures: Provide comfort measures to reduce the infant’s discomfort.
  • Frequent eye cleaning: Gently cleanse the eyes with sterile saline or water every 2–4 hours, using a separate swab for each eye.
  • Medication administration: Administer topical medications as prescribed, ensuring correct dosage and frequency.
  • Monitoring: Closely monitor the infant’s response to treatment, including assessment of eyelid swelling, discharge, and corneal clarity.
  • Pain management: Provide comfort measures as needed, such as cuddling and soothing techniques.
  • Education: Educate the parents on the importance of adherence to the prescribed treatment regimen, proper eye cleaning techniques, and the need for follow-up appointments.
Complications:
  • Corneal ulceration and scarring: This can lead to permanent visual impairment or blindness.
  • Perforation of the cornea: A serious complication that requires surgical intervention.
  • Endophthalmitis: Infection of the internal structures of the eye.
  • Meningitis (rare, but possible, particularly with gonococcal infection): Infection of the membranes surrounding the brain and spinal cord.
  • Sepsis: A life-threatening bloodstream infection.
CONJUNCTIVITIS

CONJUNCTIVITIS (RED EYE)

Conjunctivitis is defined as the inflammation of the conjunctival membrane of the eye.

Types of Conjunctivitis:
  • Bacterial Conjunctivitis: Caused by bacteria such as Staphylococcus or Streptococcus.
  • Viral Conjunctivitis: Often caused by adenovirus.
  • Allergic Conjunctivitis: Triggered by allergens like smoke, cosmetics, and medicines.
Causes of Conjunctivitis:

Bacterial:

  • Staphylococcus aureus
  • Staphylococcus epidermidis
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Less commonly, sexually transmitted infections like Chlamydia and Gonorrhea.

Viral:

  • Adenovirus
  • Enteroviruses
  • Herpes simplex virus
  • Herpes zoster ophthalmicus
  • Molluscum contagiosum
  • Measles
  • Mumps
  • Rubella
  • Infectious mononucleosis
  • HIV

Allergic:

  • Pollen
  • Animal dander
  • Dust mites
Signs and Symptoms of Conjunctivitis:

Bacterial:

  • Pinkness or redness in the eye
  • Burning, itching, a sensation of grittiness, or mild pain or discomfort in the eye
  • Increased watering of the eye
  • Thick, sticky, often yellowish discharge; can form a “crust” at night
  • Swollen eyelids
  • Slight sensitivity to bright light
  • Swelling of lymph nodes in front of the ears

Viral:

  • Pinkness or intense redness of the eye
  • Burning, grittiness, or mild pain
  • Watery discharge with a small amount of mucus
  • Crustiness around the eyelids upon waking
  • Swollen, red eyelids
  • Slight sensitivity to bright light
  • Swelling of lymph nodes in front of the ears
  • Other viral infection symptoms like a runny nose or sore throat

Allergic:

  • Watery eyes
  • Itchy eyes
  • Swollen and red eyelids
  • Slight photophobia
Management of Conjunctivitis:

Bacterial:

  • Apply chloramphenicol or gentamicin eye drops 2 or 3 hourly for 2 days, then reduce to 1 drop every 6 hours for 5 days.
  • Change treatment based on culture and sensitivity results.
  • Gonococcal conjunctivitis should be treated aggressively and in line with STI management guidelines.
  • Limit the use of steroid eye drops to short durations.
  • Mild cases often clear up within 1-2 weeks without special medical treatment.
  • Clean discharge with a clean cloth, sterile pad, or cotton wool soaked in water.
  • Apply lubricating eye drops (artificial tears) and avoid contact lenses until the infection clears.

Viral:

  • Usually, no specific treatment is required, but antibiotic ointment can reassure the patient.
  • In serious cases, systemic corticosteroids like prednisolone may be used.
  • Apply a cold or warm compress, clean discharge with warm water, and use lubricating eye drops.
  • Avoid contact lenses until the infection clears.

Allergic:

  • Apply a cold compress to soothe symptoms.
  • Use topical steroids for persistent cases but only for short periods.
  • Maintain facial hygiene.
  • Betamethasone or hydrocortisone eye drops every 1-2 hours until inflammation is controlled then applied 2 times daily.

Eye Infections in Children Read More »

Eye injuries in children paediatrics

Eye Injuries in Children

EYE  INJURIES IN CHILDREN

An eye injury refers to any trauma or damage to the eye or its surrounding structures, including the eyelids, conjunctiva, cornea, sclera, iris, lens, retina, or optic nerve. 

These injuries may result from mechanical, chemical, or thermal causes, and can range from minor irritations to vision-threatening conditions.

  • Injuries to the eye, eyelid, and area around the eye

A foreign body is an object in your eye that shouldn’t be there, such as a speck of dust, a wood chip, a metal shaving, an insect or a piece of glass.

 

Read about Foreign Bodies in the Eye by Clicking Here

Classifications of Eye Injuries

Eye injuries are categorized based on the mechanism of injury, the type of trauma, and the specific anatomical location affected.

1. Classification by Mechanism of Injury

Type

Description

Examples

Blunt Trauma

– Impact without penetration to the eye.

– Often caused by rounded objects or physical force.

– Sports injuries (e.g., ball, elbow).

– Assault (punch).

– Airbag deployment in car accidents.

Penetrating Trauma

– A sharp object pierces the eye, creating an open wound.

– Glass shards.

– Nails.

– Metallic fragments from tools.

Chemical Injuries

– Exposure to acids or alkalis, causing chemical burns and tissue damage.

– Cleaning agents.

– Industrial chemicals.

– Fertilizers or pesticides.

Thermal Injuries

– Damage caused by excessive heat exposure.

– Explosions.

– Hot oil splashes.

– Flames or heated objects.

Radiation Injuries

– Injury due to exposure to ultraviolet (UV) or infrared (IR) rays.

– Sunlight.

– Welding arcs.

– Tanning lamps.

2. Classification by Anatomical Location

Location

Description

Examples of Injuries

Eyelids

– Protect the eye but are prone to trauma such as lacerations, contusions, and burns.

– Eyelid laceration from sharp objects.

– Contusion from blunt force.

– Burn injuries.

Conjunctiva

– The thin membrane covering the white part of the eye and the inside of the eyelids.

– Subconjunctival hemorrhage.

– Conjunctival foreign body (dust, sand).

Cornea

– Transparent, dome-shaped surface responsible for focusing light.

– Corneal abrasion.

– Corneal laceration or ulcer.

– Foreign body injuries.

Sclera

– The white, outer covering of the eyeball.

– Scleral lacerations.

– Penetrating injuries causing globe rupture.

Anterior Chamber

– The fluid-filled space between the cornea and iris.

– Hyphema (blood in the anterior chamber).

Lens

– Focuses light onto the retina; prone to trauma-induced opacity.

– Traumatic cataract formation.

Retina and Optic Nerve

– Retina is the light-sensitive layer at the back of the eye; the optic nerve transmits signals to the brain.

– Retinal detachment or hemorrhage.

– Optic nerve injury (e.g., optic neuropathy).

Types of Eye Trauma

A. Blunt Trauma

Blunt trauma occurs when an object hits the eye with force but does not penetrate. This can lead to:

  • Bruise of the Eyelids (Black Eye): A black eye results from a bruise on the eyelids. The swelling and discoloration often worsen over the first few days before gradually improving over 2-3 weeks. It’s normal for the bruise to change colors as it heals.
  • Acute Hyphema (Serious): This condition involves bleeding in the space between the cornea and the iris, usually caused by blunt trauma. The blood often settles at the bottom of the cornea. Blood pooling in the anterior chamber, potentially causing increased intraocular pressure.
  • Subconjunctival Hemorrhage: This is a bright red, flame-shaped bruise on the white part (sclera) of the eyeball, caused by a scratch. It’s a mild injury that typically resolves on its own within 2 weeks.
  • Orbital Fractures: Fractures of the bones surrounding the eye, possibly affecting movement and vision.
  • Retinal Detachment: The retina separates from the back of the eye due to the force.
  • Cut or Scratch of Eyelid: Small cuts on the eyelid usually heal on their own. However, deep cuts or those that extend through the edge of the eyelid require sutures for proper healing.
  • Corneal Abrasion: A corneal abrasion is a scratch on the clear front part (cornea) of the eye. Symptoms include severe eye pain, tearing, and constant blinking. Common causes are scratches from objects like tree branches or foreign particles stuck under the upper eyelid. Most corneal abrasions are minor and heal in 2 days, but they often require a doctor’s attention.

B. Penetrating Trauma

Penetrating injuries occur when a sharp object pierces the eye. Common examples include injuries from nails, knives, or metal fragments.

  • Open Globe Injuries: The outer membrane of the eye is disrupted, requiring surgical repair.
  • Intraocular Foreign Bodies: Debris enters the eyeball, often causing infection or inflammation.
  • Punctured Eyeball (Serious): This serious injury occurs when a sharp object tears through the cornea or sclera. Tiny objects, such as those thrown by a lawnmower, can cause such punctures.

C. Chemical Injuries

Chemical injuries are caused by exposure to irritants like acids or alkalis:

  • Acid Burns: Cause coagulative necrosis, limiting deeper penetration.
  • Alkali Burns: More severe as alkalis penetrate deeper into the tissues, causing liquefactive necrosis.

D. Thermal Injuries

Thermal injuries occur due to contact with hot substances or radiant heat.

  • Superficial Burns: Affect only the eyelids and conjunctiva.
  • Deep Burns: Damage the cornea, leading to scarring or ulceration.

E. Radiation Injuries

Radiation injuries result from prolonged exposure to ultraviolet (UV) or infrared (IR) rays.

  • Photokeratitis: UV exposure damages the corneal epithelium, causing severe pain and tearing (commonly called “snow blindness” or “welder’s flash”).
  • Chronic UV Exposure: Leads to pterygium (growth of tissue over the cornea) or cataract formation.

COMMON CONDITIONS ASSOCIATED WITH EYE INJURY AND TRAUMA INCLUDE:

Scratched Eye (Corneal Abrasion): Common causes of corneal abrasions, or scratches to the eye’s surface, include getting poked in the eye or rubbing the eye when a foreign body is present, such as dust or sand. Corneal abrasions are very uncomfortable and cause eye redness and severe sensitivity to light. Scratches can also make eyes susceptible to infection from bacteria or fungi. 

Penetrating or Foreign Objects in the Eye: Seek emergency care immediately if a foreign object, like metal or a fish hook, penetrates the eye. Avoid trying to remove the object yourself. Protect the eye with a loosely taped paper cup or eye shield until help arrives.

Caustic Foreign Substance in the Eye (Chemical Burn): Getting unexpectedly splashed or sprayed in the eye by substances such as acids, alkalis, or other harmful chemicals. The basic makeup of the chemical involved can make a lot of difference, such as:

  • Acid: Generally, acids cause considerable redness and burning but can be washed out fairly easily.
  • Alkali: Substances or chemicals that are basic (alkali) are much more serious but may not seem so because they don’t cause as much immediate eye pain or redness as acids. Examples of alkali substances include oven cleaners, toilet bowl cleaners, and even chalk dust.

Eye Swelling: Eye swelling and puffy, swollen eyelids can result from being struck in the eye or stung. The best immediate treatment for this type of eye injury is an ice pack.

Subconjunctival Hemorrhages (Eye Bleeding): A subconjunctival hemorrhage involves leakage of blood from one or more breaks in a blood vessel that lies between the white of the eye (sclera) and it’s clear covering (conjunctiva). A subconjunctival hemorrhage is painless and does not cause temporary or permanent vision loss. No treatment is required. Over the course of several weeks, the blood will clear and the eye will return to a normal appearance.

Traumatic Iritis: Traumatic iritis is inflammation of the colored part of the eye that surrounds the pupil (iris) and occurs after an eye injury. Traumatic iritis can be caused by a poke in the eye or a blow to the eye from a blunt object, such as a ball or a hand. Traumatic iritis usually requires treatment. Even with medical treatment, there is a risk of permanent decreased vision.

Hyphemas and Orbital Blowout Fractures: A hyphema is bleeding in the anterior chamber of the eye, the space between the cornea and the iris. Orbital blowout fractures are cracks or breaks in the facial bones surrounding the eye. Hyphemas and blowout fractures are serious eye injuries and medical emergencies.

Eye injury symptoms

Eye injury symptoms

  • Irritation: A feeling of discomfort or itchiness in the eye.
  • Severe pain: Intense discomfort in or around the eye.
  • Pinkness/redness: Redness of the eye or the surrounding area.
  • Decreased visual acuity: Blurred or reduced vision.
  • Conjunctivitis: Inflammation or infection of the conjunctiva, often causing redness and discharge.
  • Light sensitivity: Discomfort or pain when exposed to light.
  • Drainage: Discharge of fluid from the eye, which can be clear, yellow, or green.
  • Abnormal pH: Changes in the eye’s pH level, due to chemical exposure.
  • Eye surface abrasions: Scratches or injuries on the cornea or other parts of the eye surface.
  • Tearing: Excessive production of tears.
  • Blurry vision: Inability to see clearly.
  • Watery discharge: Clear fluid draining from the eye.
  • Foreign body sensation: Feeling like something is in the eye.

Signs needing emergency care

  • Pupils not equal in size: Uneven pupil sizes can indicate serious injury.
  • Sharp objects hit the eye: Objects like metal chips can cause severe damage.
  • Skin is split open or gaping and may need stitches: Deep cuts or lacerations around the eye.
  • Any cut on the eyelid or eyeball: Lacerations in these areas can be very serious.
  • Age less than 1 year old: Infants with eye injuries need immediate evaluation.
  • Bruises near the eye: Bruising can indicate more serious underlying injury.

Management of Eye Injuries

A. Immediate/Emergency Management

Blunt Trauma:

  • Apply a cold compress to reduce swelling.
  • Elevate the head to minimize hyphema.

Penetrating Trauma:

  • Do not remove the foreign body.
  • Cover the eye with a rigid shield.
  • Refer urgently to an ophthalmologist.

Chemical Injuries:

  • Irrigate the eye immediately with copious amounts of water or saline for at least 15–30 minutes.
  • Identify the chemical and call for emergency medical care.

Thermal Injuries:

  • Cool the area with sterile saline or water.
  • Apply sterile dressing to the affected eye.

General Measures:

  • Ensure the patient remains calm and avoids rubbing the eye.
  • Administer analgesics if necessary.

Medical Management

Topical Medications:

  • Antibiotics (e.g., ciprofloxacin, moxifloxacin) to prevent infections.
  • Cycloplegics (e.g., cyclopentolate) for pain relief in corneal or anterior chamber injuries.
  • Lubricating eye drops for dryness or irritation.

Systemic Medications:

  • Oral or IV antibiotics for penetrating injuries or infections.
  • Corticosteroids for severe inflammation (under medical supervision).
  • Pain relievers (e.g., acetaminophen).

Imaging: CT scan or X-ray for intraocular foreign bodies or orbital fractures.

Surgical Management

Foreign Body Removal:

  • Surface foreign bodies removed under magnification using specialized tools.
  • Intraocular foreign bodies may require surgery.

Corneal Repairs: Suturing for corneal lacerations or perforations.

Treatment for Retinal Detachment: Procedures like pneumatic retinopexy or vitrectomy.

Repair of Ruptured Globe: Requires urgent surgical intervention.

Reconstruction of Eyelids: For severe eyelid lacerations.

Nursing Management

Assessment: Monitor pain levels, vision changes, and signs of infection.

Eye Protection: Cover the injured eye with a sterile shield or dressing.

Pain Management: Administer prescribed analgesics and ensure patient comfort.

Education: Explain the treatment plan and emphasize the importance of follow-up care.

Emotional Support: Provide reassurance to the patient and family, especially in pediatric cases.

Care of Minor Eye Injuries

Small Cuts, Scratches, or Scrapes Treatment:

  • For any bleeding, apply direct pressure on the wound using a gauze pad or clean cloth. Press for 10 minutes or until the bleeding stops.
  • Wash the wound with soap and water for 5 minutes. Protect the eye with a clean cloth.
  • Apply an antibiotic ointment (such as Polysporin) to the cut 3 times a day for 3 days. No prescription is needed.
  • Cover large scrapes with a bandage (such as Band-Aid) and change it daily.

Swelling or Bruises with Intact Skin (including a Black Eye) Treatment:

  • Apply a cold pack or ice wrapped in a wet cloth to the eye for 20 minutes to help reduce bleeding and swelling. Repeat as needed.
  • A black eye usually develops over 1 to 2 days.
  • A flame-shaped bruise on the white of the eyeball is also common.
  • After 48 hours, use a warm wet cloth for 10 minutes, 3 times per day to help reabsorb the blood.

Pain Medicine:

  • To alleviate pain, give an acetaminophen product (such as Tylenol) or an ibuprofen product (such as Advil). Use as needed.

Routine Irritations (sand, dirt, and other foreign bodies on the eye surface):

  • Wash your hands thoroughly before touching the eyelids to examine or flush the eye.
  • Do not touch, press, or rub the eye itself. Prevent the child from touching the eye (swaddling may help for babies).
  • Remove foreign bodies only by flushing, as other methods can scratch the cornea.
  • Tilt the child’s head over a basin or sink with the affected eye down, gently pull down the lower lid, and encourage the child to open the eyes wide.
  • Pour a steady stream of lukewarm water (do not heat the water) from a pitcher or faucet over the eye.
  • Flush for up to 15 minutes, checking the eye every 5 minutes to see if the foreign body has been flushed out.
  • If irritation continues after flushing, see a doctor, as particles can scratch the cornea and cause infection.
  • Administer analgesics and topical eye drops as needed.
  • Foreign bodies that remain after flushing likely require professional removal.

Embedded Foreign Body (an object penetrates or enters the globe of the eye):

If an object like glass or metal is sticking out of the eye, take the following steps:

  • Admit the child to the emergency room.
  • Cover the affected eye with a small cup taped in place to keep all pressure off the eye.
  • Keep the child (and yourself) calm and comfortable until help arrives.
  • Surgical procedures will be required to address such injuries.

Chemical Exposure:

  • Flush the eye immediately with lukewarm water for 15 to 30 minutes (see Routine Irritations for detailed steps).
  • If both eyes are affected, flush them in the shower.
  • Admit the patient to the emergency room.

Black Eyes and Blunt Injuries:

A black eye can be a minor injury but might also indicate a significant eye or head trauma.

An in-depth evaluation is necessary to rule out damage to the eye.

For a black eye:

  • Apply cold compresses intermittently: 5 to 10 minutes on, 10 to 15 minutes off. Cover ice with a towel or sock to protect the delicate eyelid skin.
  • Use cold compresses for the first 24 to 48 hours, then switch to warm compresses intermittently to help the body reabsorb the blood leakage and reduce discoloration.
  • If the child is in pain, give acetaminophen (avoid aspirin or ibuprofen, which can increase bleeding).
  • Prop the child’s head with an extra pillow at night and encourage them to sleep on the uninjured side to reduce swelling.

Advice on discharge

Instructions on Medication Use: Proper instillation of eye drops and compliance with prescribed regimen.

Activity Restrictions: Avoid strenuous activities to prevent strain on the injured eye.

Follow-Up Care: Ensure regular visits to the ophthalmologist for monitoring.

Signs to Watch For: Educate the patient about symptoms of complications like worsening pain, vision loss, or redness.

Eye Injuries in Children Read More »

Reyes syndrome

Reye’s Syndrome

REYE’S SYNDROME

Reye’s syndrome is characterized by acute noninflammatory encephalopathy and fatty degenerative liver failure. I.e It is characterized by swelling in the liver and brain.

Reye’s syndrome commonly affects children recovering from viral infection, most commonly flu or chickenpox. 

REYE’S SYNDROME pathology

Pathogenesis

  • Viral Infection: Reye’s syndrome often occurs during the recovery phase of a viral infection, such as the flu or chickenpox. The initial viral infection sensitizes the body, making it more susceptible to the subsequent development of Reye’s syndrome.
  • Mitochondrial Dysfunction: It is believed that Reye’s syndrome involves mitochondrial injury, leading to dysfunction in oxidative phosphorylation and fatty acid beta-oxidation. Mitochondria are responsible for producing energy in cells, and their dysfunction disrupts normal cellular processes.
  • Fatty Acid Accumulation: In Reye’s syndrome, there is an abnormal accumulation of fatty acids in various organs, including the liver and brain. This accumulation is thought to be a result of impaired fatty acid metabolism due to mitochondrial dysfunction.
  • Disruption of Metabolic Processes: The accumulation of fatty acids and the dysfunction of mitochondrial energy production disrupt normal metabolic processes in the body. This can lead to a decrease in blood sugar levels, an increase in ammonia and acid levels in the blood, and swelling in organs such as the brain and liver

Causes of Reye’s Syndrome

The exact cause of Reye’s syndrome is still unknown, but several factors have been linked to its development. 

  • Use of Salicylates, Particularly Aspirin: The use of a type of medicine known as salicylates, especially aspirin, in young people and children under 16 has been strongly associated with Reye’s syndrome. Aspirin has been linked to the onset of Reye’s syndrome, particularly when used during or after a viral infection such as the flu or chickenpox.
  • Underlying Metabolic Disorders: Individuals with a fatty acid oxidation disorder are more likely to develop Reye’s syndrome when exposed to aspirin during a viral illness.
  • Viral Infections: Reye’s syndrome often occurs during the recovery phase of a viral infection, such as the flu or chickenpox.
  • Other Factors: Exposure to certain toxins(aflatoxins), and  insecticides, herbicides, and paint thinner, may produce symptoms similar to Reye’s syndrome, but they do not cause the syndrome itself.
Clinical Features of Reye's syndrome (1)

Clinical Features of Reye’s syndrome

Initial Signs and Symptoms:
For children younger than age 2, the first signs of Reye’s syndrome may include;

  • Diarrhea
  • Rapid breathing

For older children and teenagers, early signs and symptoms may include;

  • Persistent or continuous vomiting
  • Unusual sleepiness or lethargy
  • Anorexia (loss of appetite)

Additional Signs and Symptoms:
As the condition progresses, signs and symptoms may become more serious, including;

  • Irritable, aggressive, or irrational behavior
  • Confusion, disorientation, or hallucinations
  • Weakness or paralysis in the arms and legs
  • Seizures
  • Excessive lethargy
  • Decreased level of consciousness
  • Hepatomegaly (enlargement of the liver)
  • Decerebration (elimination of cerebrum function in humans)
  • Papillary changes
  • Rapidly developing coma

Laboratory Investigations

  • There may be some degree of hypoglycemia with low levels of glucose in the cerebrospinal fluid.
  • Serum ammonia levels are elevated. (normal 40-80 mcg/dl)
  • Prothrombin time is prolonged
  • Hepatic enzymes are increased.
  • Liver biopsy shows fatty change and glycogen depletion but no necrosis of the liver cells.
  • EEG shows generalized slow waves.

NB: Reye syndrome should be suspected in any child exhibiting the acute onset of an encephalopathy (without known heavy metal or toxin exposure) and pernicious vomiting.

Hurwitz classification of Reyes Syndrome 

Hurwitz classification of Reyes Syndrome 

The stages used in the CDC classification of Reye’s syndrome are as follows:

Stage 0: Alert

  • Abnormal history and laboratory findings consistent with Reye’s syndrome
  • No clinical manifestations

Stage 1: Mild Symptoms

  • Vomiting
  • Sleepiness
  • Lethargy

Stage 2: Moderate Symptoms

  • Restlessness
  • Irritability
  • Combativeness
  • Disorientation
  • Delirium
  • Tachycardia (rapid heart rate)
  • Hyperventilation (rapid breathing)
  • Dilated pupils with sluggish response
  • Hyperreflexia (exaggerated reflexes)
  • Positive Babinski sign (toes flex upward when sole of foot is stimulated)
  • Appropriate response to noxious stimuli (painful stimuli)

Stage 3: Severe Symptoms

  • Obtunded (decreased alertness)
  • Comatose
  • Decorticate rigidity (abnormal posture with arms flexed and legs extended)
  • Inappropriate response to noxious stimuli

Stage 4: Critical Symptoms

  • Deep coma
  • Decerebrate rigidity (abnormal posture with arms and legs extended)
  • Fixed and dilated pupils
  • Loss of oculovestibular reflexes (no response to cold water in the ear)
  • Dysconjugate gaze with caloric stimulation (eyes do not move together in response to cold water in the ear)

Stage 5: Life-Threatening Symptoms

  • Seizures
  • Flaccid paralysis (loss of muscle tone)
  • Absent deep tendon reflexes (DTRs)
  • No pupillary response
  • Respiratory arrest

Stage 6: Unclassifiable

  • Patients who cannot be classified because they have been treated with curare or another medication that alters the level of consciousness

Medical Management of Reye’s Syndrome:

No specific treatment exists for Reye syndrome, and management is primarily focused on providing supportive care based on the stage of the syndrome. 

Stage 0-1:

  • Keep the patient quiet and frequently monitor vital signs and laboratory values.
  • Correct fluid and electrolyte abnormalities, hypoglycemia, and acidosis.
  • Maintain electrolytes, serum pH, albumin, serum osmolality, glucose, and urine output within normal ranges.
  • Consider restricting fluids to two-thirds of maintenance to avoid overhydration, which may precipitate cerebral edema.
  • Use colloids, such as albumin, as necessary to maintain intravascular volume.

Stage 2:

  • Continuous cardiorespiratory monitoring is the standard of care.
  • Place central venous lines or arterial lines to monitor hemodynamic status.
  • Use urine catheters to monitor urine output.
  • Perform an electrocardiogram (ECG) to monitor cardiac function.
  • Perform an electroencephalogram (EEG) to monitor seizure activity.
  • Prevent increased intracranial pressure (ICP) by elevating the head to 30°, keeping the head in a midline orientation, using isotonic fluids instead of hypotonic fluids, and avoiding overhydration.

Stages 3-5:

  • Continuously monitor intracranial pressure (ICP), central venous pressure, arterial pressure, or end-tidal carbon dioxide.
  • Consider endotracheal intubation if the patient is not already intubated.
Pharmacologic Management of Reye’s Syndrome:

Urea cycle disorder treatment agents:

  • Ammonia detoxicants are used to treat hyperammonemia in Reye’s syndrome.
  • Sodium phenylacetate-sodium benzoate is approved by the FDA for the treatment of hyperammonemia due to urea-cycle defects.

Antiemetic agents:

  • Antiemetic agents such as ondansetron are administered to decrease vomiting, especially during the initiation of sodium phenylacetate-sodium benzoate therapy.

Drugs to avoid

Barbiturates

  • Diazepam (Valium) and other benzodiazepines (antianxiety, muscle-relaxant, and sedative)
  • Antiepileptics
  • Acetaminophen (paracetamol)
  • Indomethacin (used to treat fever, pain, stiffness, and swelling)
Nursing Management of Reye’s Syndrome:

Nursing Assessment:

  • Stage 1: Lethargy, vomiting, and hepatic dysfunction.
  • Stage 2: Hyperventilation, hyperactive reflexes, delirium, and hepatic dysfunction.
  • Stage 3: Coma, decorticate rigidity, hyperventilation, and hepatic dysfunction.
  • Stage 4: Deepening coma, large fixed pupils, decerebrate rigidity, and minimal hepatic dysfunction.
  • Stage 5: Seizures, flaccidity, loss of deep tendon reflexes, and respiratory arrest.

Nursing Diagnosis:

  • Deficient fluid volume related to failure of regulatory mechanism.
  • Ineffective cerebral tissue perfusion related to diminished arterial or venous blood flow and hypovolemia.
  • Risk for trauma related to generalized weakness, reduced coordination, and cognitive deficits.
  • Reduced breathing pattern related to decreased energy and fatigue, cognitive impairment, tracheobronchial obstruction, and inflammatory process.

Nursing Care Planning and Goals:

  • Maintain adequate ventilation.
  • Maintain a normal respiratory status, as evidenced by a normal respiratory rate.
  • Maintain orientation to the environment without evidence of deficit.
  • Maintain skin integrity.
  • Maintain joint mobility and range of motion.

Nursing Interventions:

  • Check oxygenation status.
  • Monitor ICP (intracranial pressure).
  • Monitor blood glucose levels.
  • Assess fluid intake and output.
  • Assess cardiac, respiratory, and neurologic status.
  • Assess pulmonary artery catheter pressures.
  • Keep the head of the bed at a 30-degree angle.
  • Maintain seizure precautions.
  • Provide oxygen therapy.
  • Administer medications as ordered.
  • Administer blood products as ordered.
  • Check for loss of reflexes and signs of flaccidity.
  • Monitor the patient’s temperature.
  • Provide postoperative care if necessary.
  • Prevent impaired skin integrity.
  • Support the patient and the family

Complications

Electrolyte and fluid disturbances:

  • Electrolytes: Minerals in your body that carry an electric charge, essential for nerve and muscle function, fluid balance, and many other bodily processes.
  • Fluid disturbances: Imbalances in the amount of water in your body, which can be caused by dehydration, overhydration, or electrolyte problems.

Increased intracranial pressure (ICP):

  • ICP: Pressure inside the skull, caused by swelling of the brain, bleeding, or other factors. High ICP can compress brain tissue and damage it.

Diabetes insipidus (DI):

  • DI: A condition where the body cannot concentrate urine properly, leading to excessive urination and dehydration. This happens because the body doesn’t produce enough antidiuretic hormone (ADH), which helps reabsorb water from the kidneys.

Syndrome of inappropriate ADH secretion (SIADH):

  • SIADH: A condition where the body produces too much ADH, leading to water retention and fluid overload. This can cause confusion, seizures, and other problems.

Hypotension:

  • Hypotension: Low blood pressure, which can occur due to dehydration, heart problems, or other factors. It can cause dizziness, fainting, and even organ damage.

Arrhythmias:

  • Arrhythmias: Irregular heartbeats, which can be caused by heart disease, electrolyte problems, or other factors. They can lead to dizziness, shortness of breath, and even heart failure.

Pancreatitis:

  • Pancreatitis: Inflammation of the pancreas, which can be caused by gallstones, alcohol abuse, or other factors. It can lead to severe abdominal pain, nausea, and vomiting.

Respiratory insufficiency:

  • Respiratory insufficiency: Difficulty breathing, which can be caused by lung disease, heart failure, or other factors. It can lead to shortness of breath, fatigue, and even death.

Hyperammonemia:

  • Hyperammonemia: High levels of ammonia in the blood, which can be caused by liver failure, genetic disorders, or other factors. It can lead to confusion, coma, and even death.

Aspiration pneumonia:

  • Aspiration pneumonia: An infection in the lungs caused by inhaling food, vomit, or other materials. It can be serious, especially in people with weakened immune systems.

Poor temperature regulation:

  • Poor temperature regulation: Difficulty maintaining a stable body temperature, which can be caused by infections, medication, or other factors. It can lead to heat stroke or hypothermia.

Uncal herniation:

  • Uncal herniation: A serious complication of increased intracranial pressure where brain tissue is squeezed through a small opening in the skull, which can damage the brain stem and be fatal.

Reye’s Syndrome Read More »

Removal of foreign bodies from the ear and nose

FOREIGN BODY IN THE EAR AND NOSE

A foreign body refers to any object that is not naturally present in a specific area of the body.

Foreign bodies can be objects that are accidentally inserted or lodged in these areas, causing discomfort, obstruction, and potential complications.

FOREIGN BODY IN THE EAR AND NOSE A foreign body refers to any object that is not naturally present in a specific area of the body. Foreign bodies can be objects that are accidentally inserted or lodged in these areas, causing discomfort, obstruction, and potential complications.

FOREIGN BODY IN THE EAR:

A foreign body in the ear refers to an object that has entered the ear canal and is not supposed to be there.

Most objects that get stuck in the ear canal are placed there by the person themselves. Children who are curious about their bodies and interesting objects, are the group most often having this problem (children aged 9 months to 8 years).

The most common things they put in their ears include Beads, Food (especially beans), Paper, Cotton swabs, Rubber erasers, Small toys, Marbles, Small shells.

Types of Foreign Bodies in the Ear:

Foreign bodies in the ear can be categorized into two main groups: inanimate and animate. Inanimate foreign bodies can further be classified as organic or inorganic.

1. Inanimate Foreign Bodies: Inanimate refers to objects that lack life, consciousness, or the ability to move or grow on their own. Inanimate objects do not possess the characteristics of living organisms, such as metabolism, reproduction, or response to stimuli.
a. Organic: Organic refers to substances that are from living organisms or contain carbon-based compounds

  • Earwax: Excessive buildup of earwax can cause blockage and discomfort in the ear canal.
  • Food: Small food particles, such as beans, can accidentally enter the ear and get stuck.
  • Paper: Paper scraps or small pieces can find their way into the ear canal.
  • Cotton swabs: The improper use of cotton swabs can push wax and debris further into the ear canal, causing blockage.
  • Rubber erasers: Small rubber erasers, often used on pencils, can become lodged in the ear.
  • Small toys: Children may insert small toys into their ears out of curiosity.
  • Marbles: Small marbles can accidentally enter the ear canal and become stuck.
  • Small shells: Shells from the beach or other small objects can get lodged in the ear.

b. Inorganic: Inorganic refers to substances that are not derived from living organisms and do not contain carbon-based compounds. The also include metallic and plastic compounds.

  • Beads: Small beads can be inserted into the ear and become trapped.

2. Animate Foreign Bodies: Animate refers to objects that are alive, possess life, or exhibit characteristics of living organisms . Animate objects have the ability to move, grow, reproduce, and respond to stimuli.

  • Insects: Insects, such as flies or ants, can crawl or fly into the ear canal, especially when sleeping on the floor or outdoors. Live insects, such as bed bugs, mosquitoes, and cockroaches can access the ear too.
  • Flies may lay eggs in patients with chronic suppurative otitis media (CSOM), which hatch into maggots.

Signs and Symptoms of foreign bodies in the Ear.

  • Pain: This is often the most prominent symptom, ranging from mild discomfort to excruciating pain. The ear canal is highly sensitive, and any irritation or pressure can trigger pain.
  • Hearing Loss: Partial or complete hearing loss in the affected ear is common, especially if the object obstructs a significant portion of the ear canal.
  • Ear Discharge: Depending on the object and the time it has been present, discharge may occur. This can include blood (especially if the object is sharp), pus (indicating infection), or inflammatory fluid.
  • Itching and Irritation: The ear canal’s sensitivity can lead to intense itching and irritation, often prompting the individual to scratch or rub the ear.
  • Feeling of Fullness or Pressure: A sense of fullness or pressure in the ear is common, especially if the object is lodged deep within the canal.

Less Common

  • Nausea and Vomiting: Irritation of the ear canal can sometimes stimulate the vagus nerve, which can lead to nausea and vomiting.
  • Coughing or Throat Clearing: Similar to nausea, stimulation of the vagus nerve can also cause coughing or throat clearing.
  • Buzzing or Ringing in the Ear (Tinnitus): This may occur if the object is moving or if it irritates the inner ear structures.
  • Dizziness and Vertigo: In rare cases, a foreign body can cause inflammation or pressure build-up in the middle ear, leading to dizziness and vertigo.
  • Unsteady Walking: This can result from the dizziness and vertigo associated with middle ear dysfunction.

Based on the Object:

  • Insects: The movement of an insect within the ear can cause a buzzing sensation and discomfort.
  • Earwax Impaction: This can lead to a feeling of fullness, pressure, and hearing loss on the affected side.
Diagnosis and Investigations of Foreign Bodies in the Ear:

Diagnosis and Investigations of Foreign Bodies in the Ear:

1. Patient History: Obtain a detailed history from the patient or caregiver regarding the nature of the foreign body, duration of symptoms, and any attempts at removal. 

2. Physical Examination: Perform a thorough examination of the ear, including inspection of the external ear, otoscopy to visualize the ear canal and tympanic membrane, and assessment of any associated symptoms such as pain, discharge, or hearing loss.

3. Imaging Studies: In some cases, imaging studies may be required to further evaluate the foreign body and its location. The choice of imaging modality depends on the suspected type and location of the foreign body. Common imaging options include: 

  • a. X-ray: X-rays can be useful for detecting radiopaque foreign bodies such as metal objects or button batteries. However, they may not be able to visualize non-radiopaque objects or provide detailed information about the foreign body’s location. 
  • b. CT Scan: CT scans are more sensitive than X-rays and can provide detailed images of the ear and surrounding structures. They are particularly useful for evaluating complex or deep-seated foreign bodies.

4. Audiometry: If there is concern about potential damage to the ear or hearing loss, audiometry may be performed to assess the patient’s hearing function.

 Treatment and Management

When a patient arrives at the hospital with a foreign body in their ear, we begin by offering a warm welcome and ensuring their comfort. We then proceed with the following steps:

1. Initial Assessment:

  • Gather Biodata: We collect basic information such as name, age, contact details, and medical history.
  • Detailed History: We ask the patient about the incident, the nature of the object, the duration of the problem, and any associated symptoms. 

2. ENT Specialist Consultation:

  • Referral: The patient is promptly referred to an Ear, Nose, and Throat (ENT) specialist.: The ENT specialist examines the ear using an otoscope to visualize the foreign body and assess its location and nature.

3. Treatment Approach:

  • The ENT specialist will determine the most appropriate method for removing the foreign object based on factors such as its size, shape, material, and location. Techniques vary widely and may involve gentle suction, small forceps, looped instruments, or magnetic tools for metallic objects.
  • Ear Irrigation: If the eardrum is intact, warm water irrigation using a small catheter can be employed to flush out the object.
  • Sedation: For young children who cannot tolerate painful procedures, sedation may be necessary.

4. Specific Cases:

  • Insects: Insects in the ear canal are usually killed with lidocaine (an anesthetic) or mineral oil and then flushed out with gentle irrigation.
  • Button Batteries: These require urgent removal due to the risk of chemical burns.
  • Food or Plant Material: These need prompt attention as they can swell when moistened, causing further obstruction and discomfort.
  • Living foreign bodies can be killed by instilling oily drops into the ear, suffocating the insect, which can then be removed with forceps or a syringe.
  • Metallic foreign bodies, glass beads, and small food grains may be removed by syringing.
  • Magnets can sometimes be used if the object is metal.
  • Suction devices may also help pull out the object.
  • Use tweezers. If the object is easy to see and grasp, gently remove it with tweezers
  • After removal, re-examine the ear to check for any injury to the ear canal.
  • Antibiotic ear drops may be prescribed to prevent infection.

5. Post-Removal Care:

  • Antibiotic Drops: After the object is removed, antibiotic drops may be prescribed for 5-7 days to prevent infection. 
  • Follow-up: A follow-up appointment within a week is recommended to ensure the ear is healing properly. If any bleeding, discharge, or pain persists, further evaluation is necessary.

6. Urgent Removal Situations:

  • Significant Pain: If the foreign body causes intense pain or discomfort.
  • Hearing Loss: If there is a significant decline in hearing.
  • Dizziness: If the patient experiences dizziness or vertigo.
GENERAL MANAGEMENT
  • Don’t use forceps to try to grasp the object as it will only push it further in the ear.
  • If the foreign body has an edge to grab, remove with Hartmann forceps.
  • Syringe the ear with lukewarm water
  • If the foreign body cannot be removed by syringing, remove with a foreign body hook.
  • General anaesthesia may be essential in children.
  • Insects: Kill by using clean cooking oil or water into the ear, then syringe out with warm water.

For smooth round Foreign bodies.

  • Syringe the ear with clean Luke warm water
  • If Foreign body cannot be removed by syringing , remove with a foreign body hook.
  • General anaesthesia may be essential in children and sensitive adult
  • Do not use forceps to try to grasp round objects as this will only push them further in the ear.

For other Foreign bodies

  • If there is an edge to grab, remove with Hartmann(crocodile) forceps.

For insects in the ear

  • Kill these by inserting clean cooking oil or water into the ear, then syringe out with warm water.
  • Cockroaches are better removed by a crocodile forceps since they have hooks on their legs that make removal by syringing impossible.

For impacted seeds:

  • Don’t syringe with water as the seed may swell and block the ear, so refer immediately if you cannot remove with the hook.
  • Suction may be useful for certain Foreign Bodies
  • Magnets are sometimes used if the objects are metallic.
  • Give antibiotics ear drop to prevent infection and pain killers.

WAX IN THE EAR  OR IMPACTED CERUMEN

This is accumulation of wax in the external ear that obstructs the external acoustic meatus. 

Wax is a normal substance produced in the external ear canal and it can accumulate in it . It is made up of epithelial scales mixed with the secretions from  special glands in the skin of the outer ear. Wax in the ear is normal & usually comes out naturally from time to time . In most people, the wax escapes as it is formed but in some it remains in the ear canal forming a wax plug and cause a problem by obstructing it and causing deafness.

Causes of impacted cerumen
  • Excessive and/or thick wax production
  • Small , tortuous and/ or hairy ear canal
  • Use of ear pads
Clinical features
  • Blocked ears                                 
  • Buzzing sound
  • Sometimes there is mild pain
Management
  • Olive oil/vegetable oil or Glycerine or sodium bicarbonate or liquid paraffin ear drops can be applied three times a day for a few days and it will soften the impacted wax . After this wax may fall out by its own.
  • If it fails, then remove it by ear syringing. The  clean water used for ear syringing should be warm i.e. at body temperature and is done when the wax is soft. So as not to stimulate the inner ear and cause dizziness. The ear is then dried gently after the syringing & should be examined to exclude  any damage to the tympanic membrane.
    N.B  Advise the patient not to use any sharp object in the ear in an attempt to remove the wax as this may damage the ear drum. Don’t syringe the ear if there is history of discharge and also if there is pain.

Complications:

  • Infection: Infection of the ear canal is possible, but usually responds well to antibiotic drops.
  • Eardrum Damage: Attempting to remove a foreign body on your own can potentially damage the eardrum.
  • Persistent Symptoms: Ongoing pain, bleeding, or discharge may indicate irritation or injury within the ear.
Foreign Bodies in the Nose

Foreign Bodies in the Nose

A foreign body in the nose refers to an object that has been inserted into the nasal cavity and is causing discomfort or obstruction.

Foreign bodies in the nasal passages are common, especially in children and mentally retarded adults. They often enter through the anterior nares, but can also come from the mouth or stomach during vomiting or coughing, or be left in the nose during nasal surgery.

Types of Foreign Bodies of the Nose

  1. Small Toys: Children, especially toddlers, may insert small toys like Lego pieces, beads, or small action figures into their noses out of curiosity or during play.
  2. Pieces of Eraser: Erasers from pencils or other stationery items can break off and become lodged in the nasal cavity.
  3. Tissue: Tissue paper or small pieces of tissue can be accidentally inserted into the nose, especially in cases where someone is trying to blow their nose.
  4. Clay (used for arts and crafts): Children who play with clay or modeling compounds may accidentally insert small pieces into their noses.
  5. Food: Peas, beans, nuts, or other small food items can find their way into the nasal cavity, particularly in young children who may put objects in their noses while eating or playing.
  6. Pebbles or Dirt: Children playing outdoors may accidentally insert small stones, pebbles, or dirt into their noses.
  7. Paired Disc Magnets: Paired disc magnets, sometimes used for attaching earrings or nose rings, can be a concern if accidentally inserted into the nose. They can cause damage to the nasal tissue over time.
  8. Button Batteries: Button batteries, commonly found in watches or small electronic devices, can be hazardous if inserted into the nose. They can cause serious injury and should be treated as an emergency.

Clinical Manifestations

  • Visible foreign body
  • Nasal congestion
  • Persistent sneezing
  • Difficulty in breathing
  • Irritability
  • Persistent crying in infants
  • Blood-tinged nasal discharge
  • Rhinorrhea
  • Foul-smelling discharge

Diagnosis

  • A history of nasal obstruction and unilateral blood-stained, foul-smelling discharge should raise suspicion of a foreign body. 
  • Anterior rhinoscopy may reveal the foreign body, which might be obscured by mucopurulent discharge and granulations. 
  • Probing can detect the foreign body, and radiological examination can help identify radiopaque foreign bodies.

Management

  • The patient is usually held in an upright position, and the nasal fossae are illuminated. A curved hook is used to gently pull the foreign body forward. An Eustachian catheter is often useful for this purpose.
  • For uncooperative patients or deeply seated foreign bodies, general anesthesia may be needed.

Removal techniques

Before Removal: Reduce swelling: Apply 0.5% phenylephrine (Neo-Synephrine) to shrink the nasal lining and Provide pain relief: Use topical lidocaine to numb the area.

  1. Direct utilizing tools like forceps, curved hooks, cerumen loops, or suction catheters to directly see and remove the object.
  2. Balloon Catheter Method: Pass a thin, lubricated, balloon-tip catheter past the object. Inflate the balloon, pull it forward to move the foreign body out through the nostril for removal.
  3. Self-Removal Methods like Blowing Nose: Encourage patients to try expelling the foreign body by blowing their nose while blocking the opposite nostril.
  4. Positive Pressure Ventilation: For Uncooperative Patients: In cases where direct removal isn’t possible, positive pressure ventilation can be used. A caregiver can deliver a gentle puff of air into the mouth to help dislodge the object.  Positive pressure can also be delivered through the mouth using a bag mask (Ambu Bag) or through the nose using oxygen tubing.

Button batteries must be removed from the nose immediately because of the danger of liquefaction necrosis of the surrounding tissue.

Appropriate infection-control precautions must be taken because the foreign body will likely be expelled against the parent’s cheek and will be covered with mucus and possibly blood.

Removal of foreign bodies from the ear and nose Read More »

HEARING IMPAIRMENT

HEARING IMPAIRMENT

HEARING IMPAIRMENT

Hearing impairment is defined as an impairment in hearing, whether permanent or fluctuating, that adversely affects a person’s ability to hear and understand sounds. It can range from mild to profound.

But let's first see what Hearing means

Hearing starts when sound waves traveling through the air reach the outer ear, also called the pinna. The sound waves then travel through the ear canal to the middle ear.

In the middle ear, the eardrum (a thin tissue layer) vibrates. Three small bones called ossicles amplify these vibrations and carry them to the inner ear.

The inner ear contains the cochlea, a snail-shaped chamber filled with fluid and lined with tiny hair cells. When the vibrations move through the fluid, the outer hair cells amplify them. This amplification allows us to hear soft sounds.

The inner hair cells then translate the vibrations into electrical nerve impulses. These impulses travel along the auditory nerve to the brain, where they are interpreted as sound.

 

The cochlea is structured so that different areas detect different pitches, like the keys on a piano. From the cochlea, the sound information is transmitted to the cerebrum, where hearing interpretation takes place.

ear anatomy

Hearing Impairment:

Hearing impairment occurs when there’s a problem with or damage to one or more parts of the ear. 

  • Hearing impairment is defined as an impairment in hearing, whether permanent or fluctuating, that adversely affects a person’s ability to hear and understand sounds. It can range from mild to profound.

Deafness:

  • Deafness refers to a severe or profound hearing impairment where a person has very little or no functional hearing. Individuals who are deaf may have difficulty processing linguistic information through hearing alone and often rely on other forms of communication, such as sign language or assistive devices.
  • Deafness is defined as a degree of loss such that a person is unable to understand speech even in the presence of amplification.
  • Amplification refers to the use of hearing aids or other assistive devices to enhance sound. The statement suggests that even with the use of amplification, individuals with deafness still struggle to understand speech.

Hard of Hearing: 

  • This term is used to describe individuals who have a mild to moderate hearing loss. They may have enough residual hearing to benefit from hearing aids or other assistive devices to enhance their hearing abilities.

Hearing Loss:

  • This is a general term used to describe any degree of impairment in hearing, ranging from mild to profound. It encompasses both temporary and permanent hearing impairments.

Deafened:

  • This term is used to describe individuals who become deaf later in life, as adults. They may face different challenges compared to those who were born deaf or became deaf at a young age.
  • Anacusis:  Have no hearing at all. 

Types of hearing loss

Conductive Hearing Loss: Conductive hearing loss occurs when there is a problem with the outer or middle ear that prevents sound from reaching the inner ear. It can be caused by conditions such as ear infections, blockages in the ear canal, perforated eardrum, or abnormalities in the middle ear bones. 

  • Any process that interferes with the conductive mechanism of the ear canal, tympanic membrane, or ossicles may cause a conductive hearing loss. The most common pediatric cause of conductive loss is otitis media with effusion and is usually of mild to moderate severity. Several congenital syndromes may also be associated with middle ear abnormalities, such as Apert, Crouzon, and Treacher Collins syndromes.

Sensorineural Hearing Loss: Sensorineural hearing loss occurs when there is damage to the inner ear or the auditory nerve pathways that transmit sound signals to the brain. It is the most common type of hearing loss and is often permanent. 

  • Sensorineural hearing loss is caused by a lesion of the cochlea, auditory nerve or central auditory pathway. SNHL can be acquired or congenital, both being equally common. The most common postnatal cause of acquired Sensorineural hearing loss is meningitis, while the most common prenatal cause is intrauterine infection (e.g. TORCHES). Other causes of acquired hearing loss include prematurity, hyperbilirubinemia, perinatal hypoxia, acquired immunodeficiency syndrome, head trauma and ototoxic medications (aminoglycosides, loop diuretics).

Mixed Hearing Loss:

Mixed hearing loss is a combination of sensorineural and conductive hearing loss. It involves both a problem in the outer or middle ear and damage to the inner ear or auditory nerve. This type of hearing loss can occur when someone with pre-existing sensorineural hearing loss develops a conductive hearing loss on top of it.

Causes of Hearing Impairment (1)

Causes of Hearing Impairment:

  1. Ear Infections: Ear infections, such as otitis media, can cause hearing impairment. These infections can result in inflammation and fluid buildup in the middle ear, which can interfere with the transmission of sound to the inner ear.
  2. Blockages in the Ear: Blockages in the ear, such as foreign bodies, impacted wax, or fluid due to cold or allergies, can also lead to hearing impairment. These blockages can prevent sound waves from reaching the inner ear properly.
  3. Damage to Tympanic Membrane and Ossicles: Damage to the tympanic membrane (eardrum) or the tiny bones in the middle ear called ossicles can cause hearing impairment. A tear in the eardrum or damage to the ossicles can disrupt the transmission of sound vibrations to the inner ear.
  4. Genetic Disorders: Some genetic disorders can interfere with the development of the inner ear and auditory nerve, leading to hearing impairment. These disorders can affect the structure or function of the auditory system, resulting in varying degrees of hearing loss.
  5. Complications during Pregnancy: Certain complications during pregnancy, such as TORCHES infections (Toxoplasmosis, Other infections, Rubella, Cytomegalovirus, Herpes simplex, Syphilis), or exposure to chemotherapy drugs, can cause hearing impairment in the developing fetus.
  6. Perinatal problems: Fetal alcohol spectrum disorders are reported to cause hearing loss in up to 64% of infants born to alcoholic mothers, from the ototoxic effect on the developing fetus plus malnutrition during pregnancy from the excess alcohol intake.
  7. Premature birth can be associated with sensorineural hearing loss because of an increased risk of hypoxia, hyperbilirubinemia, ototoxic medication and infection as well as noise exposure in the neonatal units. The risk of hearing loss is greatest for those weighing less than 1500 g at birth.
  8. Sudden Loud Noise: Exposure to sudden loud noises over time can damage the tiny hair cells in the cochlea, which are responsible for transmitting sound signals to the auditory nerve. Prolonged exposure to loud noise, such as in noisy work environments or attending loud concerts without hearing protection, can lead to permanent hearing loss.
  9. Head Injury: Traumatic head injuries can also cause hearing impairment. Damage to the auditory nerve or the structures of the ear due to a head injury can result in partial or complete hearing loss.
  10. Disorders; such as 
  • Strokes: Depending on which blood vessels are affected, a stroke can cause deafness.
  • Multiple Sclerosis (MS): MS is an autoimmune disease where the immune system attacks the myelin sheath, protecting nerves. Damage to the auditory nerve can lead to complete deafness in one or both ears.
  • Perilymph fistula: A microtear in the round or oval window (membranes separating the middle and inner ear) of the cochlea allows perilymph to leak into the middle ear. This usually occurs due to trauma, including barotrauma, and can cause vertigo and hearing loss.

11. Infections:

  • Viral: Viral ear infections (labyrinthitis) can cause sensorineural hearing loss.
  • Measles, Mumps, Rubella: These childhood illnesses can cause deafness in newborns.
  • Herpes Viruses: Cytomegalovirus (CMV) can cause deafness in newborns and progressive sensorineural hearing loss in children.
  • Meningitis:: It can also lead to hearing loss.

12. Inherited:

  • Down Syndrome: Individuals with Down syndrome are more likely to experience hearing loss, often due to middle ear effusions in childhood. They can also develop high-frequency sensorineural hearing loss later in life.
  • Otosclerosis: This condition causes fixation of the stapes in the middle ear, leading to conductive hearing loss.
  • Vestibular Schwannoma (Acoustic Neuroma): This tumor can cause hearing loss by compressing the vestibulocochlear nerve.

13. Congenital Problems: Superior Semicircular Canal Dehiscence: A gap in the bone covering the inner ear can lead to low-frequency conductive hearing loss, autophony, and vertigo.

14. Medications: Ototoxic Medications: Some medications can temporarily or permanently affect hearing. Examples include loop diuretics (furosemide, bumetanide), NSAIDs, and aminoglycosides.

15. Chemicals: Environmental Toxins: Metals (lead) and solvents (toluene) can cause irreversible high-frequency hearing loss by damaging the cochlea and auditory system.

16. Physical Trauma: Head Injury: Damage to the ear or brain centers responsible for processing auditory information can lead to temporary or permanent hearing loss or tinnitus.

17. Sensorineural Hearing Impairment:

  • Genetic Disorders: Some inherited disorders affect the development of the inner ear and/or auditory nerve.
  • Ear or Head Injuries: Skull fractures can cause hearing loss.
  • Complications During Pregnancy or Birth: Infections or illnesses during pregnancy can affect inner ear development, leading to hearing impairment in newborns. Premature babies are also at higher risk.
  • Infections or Illnesses: Repeated ear infections, mumps, measles, chickenpox, and brain tumors can damage inner ear structures.
  • Medications: Certain antibiotics and chemotherapy drugs can cause hearing loss.
  • Loud Noise: Sudden loud noises or prolonged exposure to high noise levels can damage hair cells in the cochlea, leading to permanent hearing loss.

Signs, Symptoms, and Associated Conditions of Hearing Loss

Primary Symptoms:

  • Difficulty understanding speech: Trouble following conversations, especially in noisy environments. Difficulty understanding children and women (higher frequencies). Needing people to repeat themselves frequently.
  • Reduced volume perception: Sounds or speech seem dull, muffled, or attenuated. Need to increase volume on TV, radio, music, and other audio sources
  • Difficulty using the telephone: Inability to hear clearly on the phone, needing to use speakerphone or headphones
  • Loss of directionality of sound: Difficulty locating the source of sound, feeling disoriented in noisy environments
  • Difficulty discriminating speech against background noise (cocktail party effect): Trouble understanding conversations in crowded places or with background noise

Sensory Symptoms:

  • Pain or pressure in the ears
  • A blocked feeling

Secondary Symptoms:

  • Tinnitus: Ringing, buzzing, hissing, or other sounds in the ear when no external sound is present
  • Vertigo and disequilibrium: Sensation of dizziness, spinning, or imbalance
  • Tympanophonia: Abnormal hearing of one’s own voice and respiratory sounds, usually due to a patulous Eustachian tube or dehiscent superior semicircular canals
  • Disturbances of facial movement: Indicating a possible tumor or stroke, affecting cranial nerves

Other Associated Conditions:

  • Headaches: May be associated with hearing loss, especially in cases of pressure or pain in the ear.
  • Emotional distress: Hearing loss can lead to social isolation, frustration, and depression.
  • Cognitive decline: Studies suggest a correlation between hearing loss and cognitive decline, including memory problems and dementia.

According to age

Infant

  • Wakes only to touch, not environmental noises
  • Does not startle to loud noises
  • Does not turn to sound by 4 months of age
  • Does not babble at 6 months of age
  • Does not progress with speech development

Young child

  • Does not speak by 2 years of age
  • Communicates needs through gestures
  • Does not speak distinctly, as appropriate for his or her age
  • Displays developmental (cognitive) delays
  • Prefers solitary play
  • Displays immature emotional behavior
  • Does not respond to ringing of the telephone or doorbell
  • Focuses on facial expressions when communicating

Older child

  • Often asks for statements to be repeated
  • Is inattentive or daydreams
  • Performs poorly at school
  • Displays monotone or other abnormal speech
  • Gives inappropriate answers to questions except when able to view face of speaker
Classification or Grading of Hearing Loss

Classification/Grading of Hearing Loss

Hearing loss is categorized by type or severity. Furthermore, a hearing loss may exist in only one ear (unilateral) or in both ears (bilateral). Hearing loss can be temporary or permanent, sudden or progressive. 

Normal Hearing: Hearing thresholds are within the normal range, typically up to 25 decibels (dB)

  1. Mild Hearing Loss(Slight): Hearing thresholds range from 26 to 40 dB. Individuals with mild hearing loss may have difficulty hearing soft or distant speech.
  2. Moderate Hearing Loss: Hearing thresholds range from 41 to 60dB. Individuals with moderate hearing loss may have difficulty understanding speech, especially in noisy environments.
  3. Severe Hearing Loss: Hearing thresholds range from 61 to 80 dB. Individuals with severe hearing loss may rely heavily on amplification, such as hearing aids, to communicate.
  4. Profound Hearing Loss: Hearing thresholds are 81 dB or greater. Individuals with profound hearing loss have very limited or no hearing and may benefit from cochlear implants or other assistive devices.

Diagnosis and Investigations of Hearing Impairment

Diagnosis and Investigations of Hearing Impairment

1. History

  •  Case history: Hearing loss can be difficult to diagnose in infants and babies because they haven’t yet developed communication skills. However, the parents are assessed about prenatal history, delivery history whether, got birth injuries etc
  • Medical History: Healthcare providers will ask about your medical history, including the onset of symptoms, whether the hearing loss is in one or both ears, exposure to loud noise, medications taken, and any family history of hearing loss.
2. Examination:
  • Otoscopy: An otolaryngologist (ear, nose, and throat doctor) may perform a physical examination using an otoscope, a handheld device with a light and magnifying lens, to examine the ear canal and eardrum. This examination can identify structural damage, earwax buildup, or other substances that may affect hearing.
  • Tympanometry: This test measures the movement of the eardrum in response to changes in air pressure, providing information about the middle ear function.
  • Differential testing: Tests such as the Weber, Rinne, Bing, and Schwabach tests use a low-frequency tuning fork to assess auditory function and determine the type of hearing loss (unilateral/bilateral, conductive, or other).
  • Tuning Fork Test: A tuning fork test helps determine the cause of hearing loss. A vibrating tuning fork is placed against different parts of the face, head, and ears to identify where the sound is loudest. This test can help differentiate between conductive and sensorineural hearing loss.
  • Audiometry: Audiometry is a measurement of a person’s hearing sensitivity and range. It helps determine the degree and configuration of hearing loss. 
  1. Pure Tone Audiometry: This test is commonly used for individuals older than 5 years. It involves listening to pure tones at different frequencies and volumes through headphones or earplugs. The person indicates when they hear the sound, and the results are plotted on an audiogram.
  2.  Visual-Reinforcement Audiometry: This test is performed on younger children who may not understand instructions. It uses visual stimuli, such as toys or lights, to reinforce the response when a sound is heard.

3. Laboratory testing:

  • In cases of infection or inflammation, blood or other body fluids may be submitted for laboratory analysis to identify the underlying cause of hearing loss.

4. Hearing tests:

  • Speech-in-noise test: This test measures how well a person can understand speech in a noisy environment, providing an indication of their ability to hear in challenging conditions.
  • Otoacoustic emissions test: This objective hearing test can be administered to toddlers and young children who may not be able to cooperate in a conventional hearing test. It can also be useful in older children and adults.

5. Scans:

MRI and CT scans: These imaging scans can be used to identify the pathology of various causes of hearing loss. They are typically reserved for selected cases where there is a need to further investigate the underlying condition.

  • Otoacoustic Emissions (OAE) Test: This test measures the sounds produced by the inner ear in response to sound stimulation. It helps assess the function of the inner ear and can detect certain types of hearing loss.
  • Auditory Brainstem Response (ABR) Test: This test measures the electrical activity of the auditory nerve and brainstem in response to sound. It is often used for infants and young children who cannot participate in conventional hearing tests. ABR can provide information about the integrity of the auditory pathway.
nursing diagnosis hearing impairement (1)

Management of Hearing Impairment

The treatment approach depends heavily on the cause, type, and extent of hearing loss.

1. Understanding the Cause:

  • Age-related or noise-induced hearing loss: These are the most common causes and often progressive, making them irreversible. Treatment focuses on managing the loss with assistive devices.
  • Specific conditions: A few types of hearing loss respond to surgical intervention.

2. Management Strategies:

a) Assistive Devices:

  • Hearing Aids: These amplify sound to improve hearing and speech comprehension. They are customizable and adjusted by audiologists for optimal performance. Treatment of significant Sensorineural hearing loss may require the use of hearing aids from as early as 3 months of age.
  • Assistive Listening Devices: These aid in specific situations like phone calls (TTY/Textphone), watching television, or attending meetings.

b) Surgical Interventions:

  • Tympanostomy tubes: For mild to moderate conductive hearing loss, treatment options include tympanostomy tubes (to keep the tympanic membrane aerated).
  • Tympanoplasty: (surgical reconstruction of the tympanic membrane and or ossicles), if a perforation is present.
  • Superior Canal Dehiscence Correction: Surgical repair of a defect in the bone covering the inner ear can address certain types of hearing loss, autophony, and vertigo.
  • Myringotomy & Ventilation Tubes: A small incision in the eardrum (myringotomy) and insertion of ventilation tubes can address ear infections and fluid build-up.
  • Vestibular Schwannoma/Acoustic Neuroma Treatment: Radiotherapy or surgical removal of these tumors can help, but hearing preservation is often challenging.
  • Stapedectomy/Stapedotomy: Replacing or reshaping the stapes bone in the middle ear can restore hearing in cases of conductive hearing loss caused by otosclerosis.

c) Treatment of Underlying Conditions:

  • Wax or Dirt Removal: Simple ear cleaning can address some cases of hearing loss.
  • Infections: Prompt treatment of ear infections is crucial to prevent further damage.
  • Structural Problems: Surgery may be needed to repair damage to the eardrum or ossicles.

d) Cochlear Implants:

  • For severe hearing loss, a cochlear implant can bypass the damaged parts of the inner ear and directly stimulate the auditory nerve, allowing sound perception.
  • Surgery for cochlear implants in the management of childhood hearing loss. Bilateral cochlear implantation may be considered for infants as young as 12 months of age who have a profound bilateral hearing loss and may be considered even earlier if the hearing loss is due to meningitis (to bypass the damaged middle ear).
  • If a child has never had auditory stimulus (secondary to profound congenital deafness), cochlear implantation before 6 years of age is important to develop the auditory cortex for sound awareness and speech development. Sign language and deaf education programs should be considered for children who are not candidates for cochlear implantation.

3. Prevention:

  • Noise-induced hearing loss: Limiting exposure to loud noises, using hearing protection, and following guidelines for safe noise levels are crucial for prevention.
  • Congenital hearing loss: Immunizations (rubella, H. influenza, S. pneumoniae) can reduce the risk of preventable causes.
  • Regular Oto-Checkups: Routine hearing screenings can detect early signs of hearing loss and allow for timely intervention.

4. Living with Hearing Loss:

  • Communication Strategies: Learning sign language, using assistive devices, and practicing clear communication techniques can help overcome challenges.
  • Support Groups: Connecting with others facing similar experiences can provide emotional support and practical advice.

HEARING IMPAIRMENT Read More »

Congenital abnormalities of the reproductive organs

Congenital Abnormalities of the Reproductive Organs

CONGENITAL ANOMALIES OF THE FEMALE GENITAL ORGANS

These are developmental abnormalities of the reproductive female organs that occur intrauterine.

Congenital abnormalities of the female reproductive tract are developmental abnormalities in the reproductive organs that form in the embryo.

Congenital anomalies of the female genital tract result from genetic, environmental, or unknown factors. They can affect various parts of the reproductive system, including the uterus, vagina, cervix, ovaries, and external genitalia. 

They result from issues in the embryological development of the Müllerian ducts, which are the precursors to the female reproductive organs.

The Müllerian ducts are two tubes present in the developing embryo. In females, these ducts develop into the fallopian tubes, uterus, cervix, and the upper part of the vagina. Normally, these ducts fuse to form a single uterine cavity and then undergo canalization (hollowing out) to form the fallopian tubes, uterus, and upper vagina.

They can also be referred to as;

  • Uterine/vaginal anomalies
  • Mullerian anomalies
  • Mullerian duct anomalies
  • Aplasia (agenesis)

Aetiology/Causes

The cause of these disruptions in embryonic development is usually not known.

  • Genetic Factors: Inherited genetic mutations or chromosomal abnormalities. Turner syndrome (affects ovarian development), Androgen Insensitivity Syndrome (affects external genitalia development).
  • Environmental Factors: Exposure to harmful substances during pregnancy. Medications like diethylstilbestrol(DES), infections (like rubella), and toxins.
  • Unknown Factors: Sometimes, the exact cause is not known.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a disorder that occurs in females and mainly affects the reproductive system. 

This condition causes the vagina and uterus to be underdeveloped or absent, although external genitalia are normal. It is also known as Rokitansky-Küster-Hauser syndrome

Anomalies of the Vulva

Labial Hypoplasia: Underdevelopment of the labia majora or minora, or both, resulting in smaller or absent labial structures.  Labial hypoplasia is a harmless condition in which one or both sides of the labia don’t form normally during puberty. One side may be normal while the other side grows smaller or is absent.
Can cause aesthetic concerns or discomfort, especially during activities like cycling or wearing tight clothing.

Management: 

  • Often no treatment is required unless associated with functional or aesthetic concerns, which can be addressed surgically.

Labial Hypertrophy: Overdevelopment or enlargement of the labia majora or minora.
May cause discomfort, difficulty with hygiene, or self-consciousness.

Clinical Features: 

  • Enlarged labia, potentially causing discomfort, irritation, hygiene problems, difficulty with urination, or cosmetic concerns. May be asymmetric.

Management:

  • Labiaplasty: Surgical reduction to achieve a more typical size.
  • Conservative Management: Symptom management like use of padded undergarments.

Clitoral Hypertrophy: An unusually large clitoris. Size is relative and depends on age and other factors.

Clinical Features: 

  • Enlarged clitoris, possibly impacting urination, sexual function, or causing cosmetic concerns. Often associated with conditions like congenital adrenal hyperplasia (CAH).

Management: 

  • Observation, clitoroplasty (surgical reduction), hormonal therapy (if CAH is present), and psychological support are options depending on severity and associated conditions.

Fusion Anomalies: Abnormal fusion of the labia. This can range from mild to complete fusion.

  • Labial adhesion: Fusion of the labia majora, sometimes extending to the labia minora.
  • Clinical Features: Fused labia, creating an obstruction to the vaginal opening (introitus), potentially impacting urination, menstruation, and hygiene.

Management: Labiaplasty (surgical separation) is needed to create a normal vaginal opening.

Imperforate Hymen types

Anomalies of the Hymen

Imperforate Hymen: Complete coverage of the vaginal opening by the hymen.

Symptoms (S/S): Usually asymptomatic until menarche, then presents with;

  • Cryptomenorrhea (hidden menstruation)
  • Amenorrhea (primary).
  • Severe abdominal or pelvic pain due to hematocolpos (accumulation of menstrual blood).
  • Urinary retention or frequency.
  • Constipation.
  • A bulging hymen
  • Back pain.

Management: Surgical hymenectomy to create a normal vaginal opening.

Microperforate Hymen: A very small opening in the hymen, resulting in limited menstrual flow. A small opening in the hymen, causing restricted menstrual flow.

Symptoms: 

  • May cause symptoms similar to imperforate hymen but less severe.
  • Spotting, pain, and delayed complete menstrual evacuation.

Management: Minor surgical intervention to enlarge the opening.

Hymenal Variations: The hymen’s appearance varies widely among individuals, and these variations are generally considered normal unless they cause symptoms. The terms you’ve listed describe different shapes and structures:

  • Annular Hymen: This is the most common type; it’s a circular or ring-like hymen with a central opening.
  • Septate Hymen: The hymen has one or more bands of tissue dividing the opening, creating multiple smaller openings. This can sometimes interfere with menstrual flow or sexual intercourse. Pain during intercourse or tampon insertion, obstruction of menstrual flow.
  • Cribiform Hymen: The hymen has multiple small openings, giving it a sieve-like appearance. This usually does not cause problems.

 Anomalies of the Vagina

Transverse Vaginal Septum

Transverse Vaginal Septum: Horizontal band of tissue partially or completely obstructing the vaginal canal.

  • Symptoms: Primary amenorrhea, cyclic abdominal pain, and dyspareunia.
  • Management: Surgical excision to restore vaginal patency.

Vertical or Complete Vaginal Septum

Vertical or Complete Vaginal Septum: A vertical partition dividing the vaginal canal into two separate channels.

  • Potential Effects: Dyspareunia, difficulty with tampon use, or complications in childbirth.
  • Management: Surgical correction to remove the septum.

Vaginal Agenesis

Vaginal Agenesis (Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome): Absence of a vaginal canal, with a functioning uterus or absence thereof.

  • Management: Surgical creation of a neovagina using techniques such as tissue grafting, balloon dilation, or bowel vaginoplasty.
  • Use of vaginal dilators to create or maintain vaginal width.

Vaginal Atresia: Narrowing or closure of the vagina.

Anomalies of the Cervix

Cervical Agenesis

Cervical Agenesis: Absence of the cervix, leading to obstruction of menstrual flow and infertility.

  • Clinical Features: Amenorrhea (absence of menstruation); infertility; Hematometra.
  • Management: Management depends on the specific situation and may involve surgical reconstruction or assisted reproductive technologies (ART).

Cervical Hypoplasia: Underdevelopment of the cervix.

  • Symptoms: Menstrual irregularities, or recurrent pregnancy losses, early onset of cervical incompetence (inability to support pregnancy), and potential fertility problems.
  • Management: Depends on severity; fertility treatments or surgical correction may be considered. Cerclage (stitching the cervix) might be used in pregnancy.

Cervical Duplication: Presence of two cervical canals, often associated with uterine duplication.

  • Potential Effects: Obstetric complications, such as difficulty during labor.
  • Management: Surgical correction or monitoring during pregnancy.

Anomalies of the Uterus

Uterine Duplication: Two separate uterine cavities, each with its own cervix and, in rare cases, separate vaginas.

  • Potential Effects: Menstrual irregularities, infertility, or recurrent miscarriages.
  • Management: Surgical unification if symptomatic.

Unicornuate Uterus

Unicornuate Uterus: Uterus formed from one Müllerian duct, resulting in a single uterine horn.

  • Potential Effects: Increased risk of miscarriage, preterm labor, or infertility.
  • Management: Monitoring during pregnancy or surgical interventions.

Septate Uterus: A fibrous or muscular septum dividing the uterine cavity.

  • Symptoms: Infertility, recurrent pregnancy loss.
  • Management: Hysteroscopic metroplasty to remove the septum.

Uterine Agenesis: Complete absence of the uterus, often part of MRKH syndrome.

Management:

  • Neovaginal creation for sexual function.
  • Gestational surrogacy for childbearing.

Arcuate Uterus: This is a variation rather than a true anomaly. The uterine cavity has a slightly indented fundus (top portion), giving it a heart-shaped appearance. The indentation is generally shallow. It’s often considered a normal variant and doesn’t usually cause problems with fertility or pregnancy. 

Didelphys Uterus (Uterus Didelphys): This is a complete duplication of the uterus, with two separate uterine horns, each having its own cervix and often its own vagina. Pregnancy complications, such as preterm birth and ectopic pregnancy, are more likely.

Bicornuate Uterus: This is characterized by a uterus with two horns that are partially fused. There’s a single cervix, but the uterine cavity is partially or completely divided. Similar to a didelphys uterus, there’s a higher chance of pregnancy complications, including miscarriage, preterm labor, and ectopic pregnancy.

Anomalies of the Fallopian Tubes

Fallopian Tube Agenesis

Fallopian Tube Agenesis: Absence of one or both fallopian tubes.

  • Potential Effects: Infertility, depending on whether one tube is functional.
  • Management: Assisted reproductive technologies like in vitro fertilization (IVF).

Accessory Fallopian Tubes: Presence of extra fallopian tubes, in addition to the normal pair.

  • Potential Effects: Increased risk of ectopic pregnancy.
  • Management: Surgical removal of accessory tubes.

Tubal Duplication: Presence of duplicated segments in fallopian tubes.

  • Potential Effects: Infertility or ectopic pregnancies.
  • Management: Corrective surgery.

Tubal Atresia: Underdevelopment or closure of one or more segments of the fallopian tubes.

  • Potential Effects: Impaired egg transportation, leading to infertility.
  • Management: Surgery or IVF.

(a) Types of Congenital Abnormalities of the Female Reproductive System:

1. Congenital Abnormalities of the Uterus:

  • Septate uterus: A uterus with a septum dividing the cavity partially or completely.
  • Bicornuate uterus: A uterus with two separate horns.
  • Unicornuate uterus: A uterus with only one horn.
  • Didelphys: A uterus with two separate cavities and two cervixes.

2. Congenital Abnormalities of the Vulva:

  • Labial hypoplasia: Underdevelopment or small size of the labia.
  • Labial hypertrophy: Overgrowth or excessive size of the labia.

3. Congenital Abnormalities of the Hymen:

  • Imperforate hymen: A hymen that completely blocks the vaginal opening.
  • Microperforate hymen: A hymen with a very small opening.
  • Septate hymen: A hymen with a band of tissue dividing the opening.

4. Congenital Abnormalities of the Vagina:

  • Transverse vaginal septum: A wall of tissue dividing the vagina horizontally.
  • Vertical or complete vaginal septum: A complete blockage of the vagina.
  • Vaginal agenesis: Absence or underdevelopment of the vagina.

5. Congenital Abnormalities of the Cervix:

  • Cervical agenesis: Absence or underdevelopment of the cervix.
  • Cervical duplication: Presence of two cervixes.

(b) Preventive Measures of Congenital Abnormalities:

  1. Genetic Counseling: Seek genetic counseling before planning a pregnancy to assess the risk of congenital abnormalities based on family history and genetic factors.
  2. Prenatal Care: Regular prenatal check-ups and screenings can help detect and manage any potential abnormalities early on.
  3. Avoidance of Teratogens: Avoid exposure to harmful substances, such as tobacco, alcohol, drugs, and certain medications, during pregnancy.
  4. Proper Nutrition: Maintain a balanced diet rich in essential nutrients, including folic acid, which can help prevent certain congenital abnormalities.
  5. Vaccinations: Ensure that you are up to date with recommended vaccinations to protect against infections that can cause fetal abnormalities.
  6. Environmental Safety: Take precautions to avoid exposure to environmental hazards, such as radiation, chemicals, and pollutants.
  7. Managing Chronic Conditions: Properly manage chronic conditions, such as diabetes or hypertension, before and during pregnancy to reduce the risk of congenital abnormalities.
  8. Genetic Testing: Consider genetic testing, such as carrier screening, to identify any potential genetic abnormalities before conception.
  9. Avoidance of Infections: Take measures to prevent infections during pregnancy, as certain infections can increase the risk of congenital abnormalities.
  10. Emotional Support: Seek emotional support and counseling to cope with stress and anxiety during pregnancy, as these factors can impact fetal development.

General Manifestation

  1. Primary amenorrhea: Absence of menstruation by the age of 16.
  2. Abnormal menstrual bleeding: Irregular or heavy menstrual bleeding.
  3. Pelvic pain: Chronic or cyclical pelvic pain
  4. Dyspareunia: Pain during sexual intercourse.
  5. Infertility: Difficulty conceiving or carrying a pregnancy to term.
  6. Recurrent miscarriages: Multiple pregnancy losses.
  7. Abnormal external genitalia: Unusual appearance or ambiguous genitalia.
  8. Urinary or bowel complaints: Symptoms such as urinary retention or bowel dysfunction.
  9. Mass or bulging in the vaginal area: Presence of a palpable mass or bulging membrane.
  10. Renal anomalies: Associated kidney abnormalities, such as unilateral agenesis or horseshoe kidney.

General Investigations for Congenital Abnormalities of the Female Reproductive System:

Medical History and Physical Examination:

  • A detailed medical history, including family history.
  • A thorough physical examination helps identify external genital abnormalities and assess the overall development of the reproductive organs.

Imaging Studies:

  • Ultrasound: This non-invasive imaging technique uses sound waves to visualize the reproductive organs and detect any structural abnormalities.
  • Magnetic Resonance Imaging (MRI): MRI provides detailed images of the reproductive organs and can help identify complex abnormalities.

Hormonal Testing:

  • Hormone levels can be assessed through blood tests to evaluate the functioning of the reproductive system and identify any hormonal imbalances.

Genetic Testing:

  • Genetic testing, such as karyotyping, can be performed to identify chromosomal abnormalities that may contribute to congenital reproductive system abnormalities.

Hysterosalpingogram (HSG):

  • HSG is an X-ray procedure that involves injecting a contrast dye into the uterus and fallopian tubes to evaluate their structure and detect any blockages or abnormalities.

Laparoscopy:

  • Laparoscopy is a minimally invasive surgical procedure that allows direct visualization of the reproductive organs using a small camera inserted through a small incision in the abdomen.

Biopsy:

  • In some cases, a biopsy may be performed to obtain a tissue sample for further examination and to rule out any underlying pathology.

General Management

Multidisciplinary Approach:

  • A multidisciplinary team consisting of gynecologists, pediatricians, geneticists, psychologists, nurses, and other specialists is often involved in the management of congenital abnormalities.

Surgical Interventions:

  • Surgical correction may be necessary for certain congenital abnormalities, such as blockages in the vagina or uterus.
  • The timing of surgery depends on the specific abnormality and the individual’s age and development.
  • Surgical procedures may be performed in infancy or delayed until the individual reaches puberty and has started menstruating.

Dilator Therapy:

  • For individuals born without a vagina, dilator therapy can be used to create a new vagina.
  • This nonsurgical approach involves using a dilator to gradually stretch or widen the area where the vagina should be.
  • Dilator therapy typically takes several months to achieve the desired outcome.

Hormonal Management:

  • Hormonal therapy may be considered to regulate menstrual cycles, manage hormonal imbalances, or address associated conditions.
  • Hormonal treatments can help alleviate symptoms such as menstrual pain or irregularities.

Emotional Support and Counseling:

  • Coping with a congenital abnormality of the reproductive system can be emotionally challenging for individuals and their families.
  • Emotional support, counseling, and support groups can provide valuable guidance, education, and a safe space for individuals to share their experiences.

Fertility Considerations:

  • Depending on the specific abnormality, fertility may be affected.
  • Fertility preservation options, such as oocyte or embryo cryopreservation, may be discussed with individuals who desire future fertility.

Congenital Abnormalities of the Reproductive Organs Read More »

Fibroids are non-cancerous growths in the muscle layer of your uterus (womb). Fibroids are very common. They are also known as myomas. Fibroids can vary in size, from being tiny to being the size of a melon.

Uterine Fibroids

FIBROIDS (FIBROMYOMAS)

Fibroids are benign / non-cancerous tumors that originates from the smooth muscle layer (myometrium) of the uterus.

Fibroids are non-cancerous growths in the muscle layer of the uterus (womb). Fibroids are very common. They are also known as myomas. Fibroids can vary in size, from being tiny to being the size of a melon.

This tumor is composed of smooth muscle and fibrous connective tissue. Other common names are: uterine leiomyoma, myoma, fibromyoma, fibroleiomyoma.

They occur usually after the age of 30 years and commonly in women who have not had children. It is predominantly an estrogen-dependent tumor.

Risk factors for uterine fibroids

Risk factors for uterine fibroids

  1. Age: Uterine fibroids are more common in women between the ages of 30 to 40 years.
  2. Parity: Women who have never given birth (nulliparous) or have had few pregnancies (low parity) are at a higher risk.
  3. Race: Uterine fibroids are more prevalent in individuals of African descent (negro or black) compared to those of Caucasian (white) ethnicity.
  4. Family History: If a woman has close relatives (such as mother, sister) with a history of uterine fibroids, her risk may be increased.
  5. Hyper-estrogenemia: Elevated levels of estrogen, a female hormone, can promote the growth of fibroids.
  6. Obesity: Being overweight or obese is associated with a higher risk of developing uterine fibroids.
  7. Early Onset of Menarche: Starting menstruation at a young age may be linked to an increased likelihood of fibroid development.
  8. Low Level of Vitamin D: Some studies suggest that insufficient vitamin D levels might be associated with a higher risk of uterine fibroids.
  9. Drugs (Estrogen Replacement Therapy): Long-term use of estrogen replacement therapy, particularly without progesterone, can be a risk factor for uterine fibroids.
Classes or types of Uterine fibroids Submucosal Fibroids: These fibroids grow into the uterine cavity. They are located just beneath the inner lining of the uterus (endometrium). Submucosal fibroids can cause various symptoms, including heavy menstrual bleeding and infertility. Intramural Fibroids (Interstitial): Intramural fibroids are the most common type and grow within the muscular wall of the uterus, known as the myometrium. They may expand and distort the shape of the uterus, leading to pain, pressure, and other symptoms. Subserosal Fibroids: These fibroids grow on the outside surface of the uterus. They can project outward and may become quite large. Subserosal fibroids can cause pelvic pain and pressure on nearby organs. Cervical Fibroids: Located on the cervix, the lower part of the uterus, cervical fibroids are relatively rare. They may cause symptoms such as pain and discomfort, and in some cases, they can affect fertility or lead to difficulties during labor. Pedunculated Fibroids: These fibroids are attached to the uterus by a narrow stalk or pedicel that contains blood vessels. Pedunculated fibroids can be either subserosal or submucous, depending on their location. Fibroid of the Broad Ligament: This type of fibroid develops in the broad ligament, which is a supportive structure that helps hold the uterus in place within the pelvis. Broad ligament fibroids are relatively uncommon and may require specific management depending on their size and location.

Classes or types of Uterine fibroids

  1. Submucosal Fibroids: These fibroids grow into the uterine cavity. They are located just beneath the inner lining of the uterus (endometrium). Submucosal fibroids can cause various symptoms, including heavy menstrual bleeding and infertility.
  2. Intramural Fibroids (Interstitial): Intramural fibroids are the most common type and grow within the muscular wall of the uterus, known as the myometrium. They may expand and distort the shape of the uterus, leading to pain, pressure, and other symptoms.
  3. Subserosal Fibroids: These fibroids grow on the outside surface of the uterus. They can project outward and may become quite large. Subserosal fibroids can cause pelvic pain and pressure on nearby organs.
  4. Cervical Fibroids: Located on the cervix, the lower part of the uterus, cervical fibroids are relatively rare. They may cause symptoms such as pain and discomfort, and in some cases, they can affect fertility or lead to difficulties during labor.
  5. Pedunculated Fibroids: These fibroids are attached to the uterus by a narrow stalk or pedicel that contains blood vessels. Pedunculated fibroids can be either subserosal or submucous, depending on their location.
  6. Fibroid of the Broad Ligament: This type of fibroid develops in the broad ligament, which is a supportive structure that helps hold the uterus in place within the pelvis. Broad ligament fibroids are relatively uncommon and may require specific management depending on their size and location.

Causes of Uterine Fibroids.

Causes of uterine fibroids are not fully understood, but research suggests that hormones and genetics play significant roles in their development. 

  1. Hormones: The hormones estrogen and progesterone, which regulate the menstrual cycle, have a close association with the growth and development of uterine fibroids. During each menstrual cycle, the lining of the uterus (endometrium) thickens under the influence of estrogen and progesterone. These hormones also seem to stimulate the growth of fibroids. As a result, fibroids often grow and enlarge during the reproductive years when hormone levels are at their highest. Conversely, as hormone production decreases during menopause, fibroids tend to shrink and become less symptomatic.
  2. Genetics: There is evidence to suggest that genetics can play a role in the development of uterine fibroids. Women with a family history of fibroids are at a higher risk of developing them themselves. This suggests that certain genetic factors may predispose individuals to fibroid formation.
  3. Other Factors: Although hormones and genetics are the main factors associated with uterine fibroids, some other factors may contribute to their development or growth. These factors include obesity, race (fibroids are more common in women of African descent), and dietary factors.

Clinical Presentation of Uterine Fibroids.

  1. Painful and Prolonged Menstrual Periods: Fibroids can cause heavy and prolonged menstrual bleeding, leading to painful periods (dysmenorrhea).
  2. Vaginal Bleeding after Menopause: Postmenopausal women with fibroids may experience vaginal bleeding, which is abnormal after menopause.
  3. Difficulty with Urination and Constipation: Large fibroids or fibroids pressing on the bladder can cause frequent urination or difficulty emptying the bladder. Fibroids pressing on the rectum can lead to constipation.
  4. Pressure in the Pelvic Area: Women with fibroids may feel pressure or heaviness in the lower abdomen or pelvis.
  5. Fullness or Pressure in the Belly: Enlarged fibroids can cause the abdomen to appear distended and feel full.
  6. Lower Back and Leg Pain: Some women may experience lower back pain or pain in the legs due to the pressure exerted by fibroids on surrounding structures.
  7. Pain During Sex (Dyspareunia): Fibroids can cause pain or discomfort during sexual intercourse.
  8. Difficulty in Getting Pregnant (Infertility): Depending on their size and location, fibroids can interfere with the implantation of a fertilized egg or lead to difficulties in conception.
  9. Pressure Symptoms: Fibroids can create pressure on the bladder, leading to increased frequency of urination. They can also exert pressure on the rectum, causing constipation. Additionally, pelvic vein pressure can lead to hemorrhoids and varicose veins.
  10. Acute Degeneration: In some cases, fibroids may undergo acute degeneration, which can cause severe pain.
  11. Enlargement of the Abdomen: Large fibroids or multiple fibroids can cause the abdomen to become visibly enlarged due to their projection into the abdominal cavity.
Diagnosis and Investigations of Uterine Fibroids.

Diagnosis and Investigations

  1. History Taking: A comprehensive medical history is taken to understand the patient’s symptoms, menstrual patterns, reproductive history, and any relevant medical conditions. This helps in assessing the likelihood of uterine fibroids and guides further evaluation.
  2. Physical Examination: A physical examination is conducted to assess general health and look for specific signs related to uterine fibroids. This may include checking for signs of chronic anemia (pallor) due to heavy menstrual bleeding.
  3. Abdominal Examination: An abdominal examination is performed to detect any large pelvi-abdominal swelling, which can be associated with significant fibroid growth.
  4. Pelvic Examination: During a pelvic examination, the healthcare provider assesses the size, shape, and position of the uterus. Uterine fibroids may cause the uterus to be symmetrically or asymmetrically enlarged. A speculum examination may also reveal the presence of fibroid polyps.
  5. Investigations: Various diagnostic tests are used to confirm the presence of uterine fibroids and assess their characteristics. These investigations may include:
  • Pregnancy Test: To rule out pregnancy as a cause of symptoms.
  • Full Blood Count (FBC) and Iron Studies: To check for anemia, which can result from heavy menstrual bleeding caused by fibroids.
  • Pelvic Ultrasound (U/S): An ultrasound is a common imaging test used to visualize the uterus and detect fibroids. It is a non-invasive and relatively simple procedure.
  • Saline Hysterosonography: This procedure involves injecting saline into the uterus during an ultrasound to enhance visualization of the uterine cavity and identify submucous fibroids.
  • Hysterosalpingogram (HSG): An HSG is an X-ray procedure that uses contrast dye to visualize the uterine cavity and fallopian tubes. It can help detect intrauterine fibroids.
  • Transvaginal Ultrasound (TVUSS): This type of ultrasound involves inserting a small probe into the vagina for a clearer view of the pelvic organs, which can be especially useful in obese patients.
  • Hysteroscopy: A hysteroscope, a thin, lighted instrument, is used to directly visualize the uterine cavity, enabling the identification and removal of submucous fibroids.
  • Bimanual Examination: A two-handed examination of the pelvic organs to assess the size, shape, and mobility of the uterus and detect any abnormal masses.
  • MRI (Magnetic Resonance Imaging): Although not always necessary, MRI is highly accurate in providing detailed information about the size, location, and number of fibroids.

Management of Fibroids.

Most fibroids do not require treatment unless they are causing symptoms. After menopause, fibroids usually shrink, and it is unusual for fibroids to cause problems. The choice of management depends on several factors:

  • Age
  • Parity
  • Size and location of fibroids
  • Desire for uterine preservation
  • If need for more children

For example:

  • Multiple myomas and completed childbearing benefit from hysterectomy.
  • Nulliparous women may undergo myomectomy.
  • Submucosal myomas can be treated with hysteroscopic resection.
  • Subserosal pedunculated myomas can be removed through laparoscopic resection.

Emergency Treatment:

  • Blood transfusion is given to correct anemia.
  • Emergency surgery is indicated for infected myoma, acute torsion, and intestinal obstruction.

Medical Management:

The aim of medical management for fibroids is to;

  • Alleviate symptoms, 
  • Reduce fibroid size, 
  • Manage associated complications without the need for invasive surgical procedures. 

This approach is particularly beneficial for women who wish to preserve fertility, avoid surgery, or are approaching menopause when fibroids naturally shrink.

1. Non-steroidal Anti-inflammatory Drugs (NSAIDs): Ibuprofen

  • NSAIDs help reduce pain and inflammation associated with fibroids. They are particularly useful in managing dysmenorrhea (painful periods).

2. Anti-fibrinolytic Agents: Tranexamic acid

  • Function: These agents reduce heavy menstrual bleeding (menorrhagia) by promoting blood clotting and stabilizing blood clots.

3. Hormonal Treatments

  • Low-dose Birth Control Pills and Intrauterine Devices (IUDs) with Hormones: Mirena (levonorgestrel-releasing IUD): These methods help control heavy menstrual bleeding by regulating hormonal levels, thinning the endometrial lining, and reducing menstrual flow.

4. Haematinics: Ferrous sulfate, folic acid

  • These supplements help improve hemoglobin levels and treat anemia caused by heavy menstrual bleeding.

5. Danazol

  • Danazol, with its anti-estrogenic effects, reduces fibroid size and controls symptoms by lowering estrogen levels, which fibroids depend on for growth. However, its use is limited due to significant side effects.

6. Gonadotropin-Releasing Hormone (GnRH) Agonists: Lupron, Synarel

  • GnRH agonists reduce estrogen and progesterone production, leading to a temporary menopausal state. This significantly shrinks fibroids and alleviates symptoms. These are usually used short-term due to their side effects and are often given before surgery to reduce fibroid size.

7. Anti Progesterones: Mifepristone (25-50 mg twice weekly)

  • As a progesterone receptor inhibitor, mifepristone reduces the size of fibroids and decreases bleeding by blocking the hormone progesterone, which is essential for fibroid growth.

Surgical Management:

Myomectomy: Surgery to remove one or more fibroids. Indicated when conservative treatments fail and the woman desires to preserve fertility or retain the uterus. Indications:

  • Young women needing more children
  • Small or few fibroids
  • Heavy or prolonged bleeding

Hysterectomy: Removal of the uterus. Indications:

  • Possible malignant changes
  • Large fibroids or numerous small fibroids
  • Completed family or approaching menopause

Endometrial ablation: Removing the lining of the uterine wall

Uterine artery embolization: Limiting blood supply to the myoma

Minimally Invasive Treatments

  • Radiofrequency Ablation: Shrinks fibroids by inserting a needle-like device into the fibroid through the abdomen and heating it with radio-frequency (RF).
  • Uterine Artery Embolism: Catheterization via the femoral artery with the injection of polyvinyl particles to reduce blood supply to the uterus, causing fibroids to shrink due to ischemia.
Pre and Post Operative Care/Management

This involves providing care for patients undergoing  surgery of gynecological procedures. 

1. Admission and History Taking:

  • Obtain personal, medical, social, and gynecological history.
  • Conduct a physical examination, including vital signs (temperature, respirations, blood pressure, and pulse), head-to-toe examination to rule out anemia, dehydration, jaundice, and vaginal examination to assess any abnormalities.
  • General assessment by the gynecologist.

2. Informed Consent: Explain the reasons for the operation, its benefits, risks, and expected results to the patient and involve the partner if necessary.

3. Investigations: Conduct various tests, including urinalysis, hemoglobin (HB) level, blood grouping and cross-match, abdominal ultrasound scan, urea and electrolytes, INR/PT (International Normalized Ratio/Prothrombin Time), and ECG/ECHO if required.

4. Patient Education: Educate the patient about the surgery, its purpose, potential complications, and side effects of anesthesia. Provide reassurance and counseling to relieve anxiety.

5. Preparing for Surgery:

  • Ensure the patient fasts from food and drinks on the day of the operation.
  • Arrange for IV line insertion, blood booking in the laboratory, and catheterization of the patient.
  • Administer pre-medications as prescribed.

6. Assisting with Theatre Preparation:

  • Help the patient change into a theater gown.
  • Continue providing counseling and emotional support.
Post-Operative Management:
  • After the operation, prepare the post-operative bed for the patient.
  • Obtain reports from the surgeon, recovery room nurses, and anesthetists.
  • Wheel the patient to the ward.
  • Receive the patient in a warm bed, keeping her in a flat position, or turning her to one side depending on the surgery type (supine for abdominal surgery or a comfortable position for vaginal surgery).

Observation:

  • Monitor the patient closely, taking vital signs regularly (every ¼ hr for the first hour and every ½ hr for the next hour until discharge).
  • Observe temperature, pulse, respiration, blood pressure, and signs of bleeding or edema at the surgical site.
  • Check the IV line and blood transfusion line if applicable.

Upon Consciousness:

  • Gently welcome the patient from the theater, explain the surgery, and assist with face sponging.
  • Provide a mouthwash and change the gown.

Medical Treatment:

  • Administer analgesics, such as Pethidine 100mg every 8 hours for 3 doses, and switch to Panadol to complete 5 days.
  • Prescribe antibiotics, such as ampicillin or gentamicin, as ordered.
  • Offer supportive care with vitamins like vitamin C, iron, and folic acid.
  • Monitor and care for the wound in case of abdominal surgery, leaving the wounds untouched if bleeding occurs and re-bandaging if necessary.

Nursing Care:

  • Assist the patient with hygiene, including bed baths and oral care.
  • Allow the patient to feed herself as soon as she is able and provide plenty of fluids.
  • Encourage regular bowel and bladder emptying, offering assistance as needed.
  • Initiate chest and leg exercises to avoid swelling and bleeding in the wound.
  • Gradually increase the exercise routine to prevent deformities and contractures.

Vaginal Surgery Management:

  • Insert a vaginal pack to control hemorrhage and inspect it frequently for severe bleeding.
  • Apply vulval padding after pack removal until bleeding stops, changing it when necessary to prevent infections.
  • Swab or clean the vulva at least every 8 hours to prevent infection.

Advice on Discharge:

  • For Myomectomy patients, advise avoiding conception for 2 years following the operation and delivering via cesarean section.
  • For hysterectomy patients, inform them that they will not conceive again or have periods.
  • Recommend abstaining from sexual intercourse for about 6 weeks and avoiding douching. Vaginal bleeding may persist for up to 6 weeks.

Complications of Uterine Fibroids:

  • Menorrhagia (heavy menstrual bleeding)
  • Premature birth, labor problems, and miscarriage
  • Infertility
  • Twisting of the fibroids
  • Anemia
  • Urinary tract diseases
  • Postpartum hemorrhage

Complications during pregnancy and labor may include:

  • Antepartum hemorrhage (placenta previa, placental abruption)
  • Abortion
  • Fetal restricted growth
  • Malpresentation
  • Cesarean section
  • Labor dystocia
  • Premature labor
  • Uterine inertia leading to postpartum hemorrhage
  • Obstructed labor
  • Subinvolution of the uterus with increased lochia.

Uterine Fibroids Read More »

Post-Operative Nursing Care

Post-Operative Nursing Care

Post-Operative Nursing Care

Post-operative nursing care refers to the specialized care provided to patients following a surgical procedure. This care focuses on monitoring, managing, and supporting the patient’s recovery through a variety of interventions and assessments.

Aims or principles of post-operative care

  1. Prevent, Recognize, and Treat Complications: Through skillful observation and application of knowledge, proactively identify and manage potential complications throughout the recovery period, from unconsciousness to discharge.
  2. Ensure Patient Comfort: Prioritize pain management, provide emotional support, and create a comfortable and safe environment to promote healing and well-being.
  3. Restore Maximum Health and Independence: Guide the patient towards optimal physical and functional recovery, enabling them to regain their independence and return to their desired lifestyle.
post operative recovery room

Immediate care of a patient recovering from anesthesia

Transporting the patient from the operating room to the recovery room

Following the completion of the operation, the operating room staff generally dresses the patient in a clean gown and moves the patient to the stretcher. Care is taken to avoid:

  • Exposing the patient, which predisposes them to respiratory infections and shock.
  • Rough handling, which may place a strain on the sutures.
  • Hurried movements and rapid position changes, which predispose the patient to hypotension.

Recovery Room Care

After arriving, the patient is either transferred to a bed from a stretcher or left on the couch. The patient is positioned supine with the head turned to one side and the chin extended forward. This is done because the patient is unconscious or semi-conscious from anesthesia, and this position helps to avoid respiratory obstruction from a relaxed tongue falling back into the throat, or by aspiration of mucus, blood, and/or vomitus. This positioning also allows secretions to flow out or for easy suctioning.

Baseline assessment of the patient is done, including:

  • Vital signs: blood pressure, pulse, respiratory rate, airway patency, depth of respirations, chest expansion, and the color of the skin.
  • Visual assessment of the patient, presence of IV infusions, drains, or special equipment.
  • The time of admission to the recovery room.
  • The absence of reflexes, e.g., pharyngeal or swallowing reflex, to ensure proper positioning of the head (lateral head position with the neck extended forward until the patient is swallowing).
  • The patient’s level of responsiveness upon admission (e.g., touch, pain, sound, movement, etc.).
  • The temperature and vital signs, which are taken every 15 minutes until stable, then every 30 minutes for the next 2-3 hours. Temperature is taken every 2-4 hours, depending on recovery policy.
  • The quality and rate of respirations. If in distress, oxygen is given, and the anesthetist is informed of respiratory depression or change in ventilatory pattern. Arterial blood gas is determined, and mechanical breathing aids are employed to resuscitate the patient (e.g., intubation, tracheostomy, ambu-ventilation, suctioning, etc.).
  • The presence of an airway/mouthpiece meant to keep the tongue from falling back. Sometimes the patient may push this away as they regain consciousness.
  • Skin color and dryness. A pale, cold, sweating skin is one sign of shock. Also, observe the lips and nail beds for pallor and cyanosis. Run the fluids as prescribed.
  • The condition of the dressing: if soiled, note the color, type, and amount of drainage.
  • The presence of drainage tubes (e.g., thoracic, abdominal, gastric catheters). Check if the patent, clamped, whether to be connected to suction apparatus, and whether they are draining.
  • The IV infusions: note the type of IV infusion solutions, amount left in the bottle, the rate of the drip, infiltrations, and orders for any other fluid to follow. Check if medications have to be added to the IV or if there are orders for any to be added.
  • The presence of a blood transfusion: note if BT is running or if one is ordered. Watch the rate of the drip and carefully for signs of a reaction.
  • Any unusual symptoms like airway obstruction, arrhythmias, signs of shock, hemorrhage, marked temperature elevation, and signs of circulatory overload from excess IV fluids.

After the patient stabilizes (i.e., in 2-3 hours) and recovers from anesthesia, they are discharged from the recovery room by the anesthetist or surgeon. The ward nursing staff is informed to come and collect the patient.

Patient is Collected from the Recovery Room Back to the Ward

  • The ward nurses are informed about the patient to be collected from the recovery room after stabilizing.
  • A verbal report is given by the recovery room nurse to the two nurses who have come to collect the patient. This report covers the type of operation done, vital signs, the level of consciousness, wound status and drainages, infusions and blood transfusions, resuscitation done, anesthesia, problems the patient had during surgery (such as vomiting or stoppage of breathing), urinary drainage, and other post-operative instructions.
  • Brief taking of vital parameters is done by the ward nurses to confirm the report from the theater and to prove that the patient is alive.
  • The patient is rolled back to the ward with the legs in front and the head behind for easy resuscitation by the nurse behind should there be any problem.
  • The patient is gently lifted from the stretcher to the bed prepared before, and care of the anesthetized patient is instituted immediately.
on ward post operative

Immediate Post-Operative Care in the Ward

Care of Anesthetized Patient in the Ward:

The patient should not be left alone during this period because of the danger of asphyxiation, shock, falls, and hemorrhage.

Position:

  • This varies with the type of surgery. It can be supine with the head turned to one side to prevent the bulky tongue from falling back by gravity over the pharynx and blocking the airway, and to promote drainage of saliva from the mouth.
  • The head can be made lower than the shoulders to prevent the flow of fluids into the trachea, allowing secretions to pool in the cheek, making removal easier, and preventing obstruction and pneumonia. The usual position is modified Sims.

Respiratory Status: Assess the quality, depth, and rate of respirations, as well as the skin color and temperature, which indicate adequate oxygen exchange.

Neurologic Status/Level of Responsiveness: Determine whether the patient is alert and oriented, unconscious, confused, restless, etc.

Cardiovascular Status: Obtain vital signs, and check the color and temperature of the skin.

Wound:

  • Check for drainage and bleeding, and connect any drainage tubes to the suction machine or collection bag.
  • See if the dressings are soiled, and look and feel under the patient to detect pooling of blood.

Tubes: Ensure catheters, NGTs, and infusion lines are patent, check the rate and amount, look for drainage or blockage, and verify proper attachment to drainage systems.

Discharge Advice/Health Education on Home Care of the Patient:

  • The length of time needed for a patient to recover from surgery depends on the patient’s physical and mental condition prior to surgery, the magnitude of the surgery, and the development of any post-operative complications.
  • Assess the knowledge and understanding of the patient about the surgery and the preventive measures.
  • Look for learning readiness and the ability of the patient and/or family members to provide care and skills needed to perform procedures at home.
  • Teach the patient to report pain in any area, temperature elevation, cough and sputum of abnormal color, loss of energy, nausea and vomiting, change in urine characteristics, difficulty in breathing, abnormal drainage, and sudden weight loss. These are signs of complications.
  • Emphasize the importance of hand washing prior to meals, performing any procedure of care, and toileting.
  • Practice together with the patient coughing, breathing, and exercises to prevent pulmonary complications.
  • Advise the patient to avoid smoking or contact with people with RTIs.
  • Encourage the patient to continue with physical exercises, increase activity when necessary, and stop when tired. Exercises promote activity to maintain circulation and normal functioning of the systems.
  • Inform the patient to take plenty of fluids, vitamins, and electrolytes to maintain fluid/nutritional status for health (wound healing, skin integrity, elimination, liquefy secretions).
  • Teach the patient how to care for the wound: dressing change, cleansing, and skin care. Allow practicing aseptic technique in wound care and protection of the wound when bathing to maintain a clean, dry, healing wound.
  • Educate the patient on how to take drugs: checking their actions, dose, route, frequency, side effects, and food and drug interactions to ensure compliance.
  • Instruct the patient to modify their home environment to clear pathways of rugs, provide good lighting, and use articles to hold onto when walking, wearing firm and good-fitting shoes to ensure safety and prevent accidents.
  • Discuss the care of appliances such as fixators, plaster of Paris, and prostheses for the purpose of safe usage and optimal effect of supportive aids.
  • Provide information on where to find supplies and equipment for home care.
  • Give the patient contact information and the phone number of the doctor or other staff for easy follow-up or emergency calls.

POST OPERATIVE CARE

Requirement

  • As for Postoperative bed

Procedure

Steps

Action

Rationale

1

Two ward nurses (Senior and Junior) collect the patient from the theatre.

To ensure the patient’s safety.

2

Receive full report of the patient’s condition from Surgeon, anaesthetist and theatre nurse.

To promote continuity of quality care and legal purpose.

3

Take the patient to the ward while observing consciousness, color of the patient and maintain a clear airway.

–

4

Screen the patient bed.

To ensure privacy.

5

Pull the prepared bed away from the wall and push the theatre trolley up against the bed. Roll the patient from trolley to bed.

This enables safe lifting of the patient.

6

Position the patient in an appropriate position depending on the surgery done and making sure the airway is maintained clear.

To maintain patient airway and aid free drainage of secretions.

7

Leave the airway piece in position until the patient regains consciousness.

To prevent the tongue from falling back and causing obstruction.

8

Check the surgeon’s post-operative instructions regarding operation and care i.e. intravenous fluid therapy, medicines, nutrition, and positioning.

To promote continuity of quality care.

9

Stay with the patient until the patient is conscious. Take vital observations as prescribed or at intervals ¼ to ½ hourly depending on the patient’s condition.

Monitor and evaluate patient’s conditions and timely interventions.

10

Observe the incision site for bleeding and drainage tubes for functionality.

–

11

Carry out special nursing procedures as prescribed i.e. suction, intravenous fluids.

–

12

Provide warmth to the patient.

To prevent hypothermia.

13

Document all the care provided and report accordingly.

Monitor progress and provide appropriate interventions.

14

Give a pillow to the patient when fully conscious, and more pillows as required.

To aid comfort.

15

Observe fluid intake; give Intravenous fluids as prescribed and encourage oral fluid as indicated; measure and record in fluid balance chart.

Monitor fluid balance.

16

Observe fluid output: Encourage the patient to pass urine or empty the drainage bag, measure and record the amount passed.

–

17

Administer post-operative medicine as prescribed by the doctor.

Promote healing or treat pain.

18

Assist the patient to perform different exercises as taught before operation.

Prevent post-operative complications.

19

Offer general nursing care to postoperative patient.

–

Points to Remember:

  • Take note of the irregularities in vital observations:

    • A rising pulse rate and/or decreasing pulse volume.

    • A falling or inaudible blood pressure recording.

    • Slowing, rapid, or noisy respirations.

  • For the skin note; the color, feel of the skin, i.e. cold or clammy.

  • Dressing; note, any oozing or bleeding from the incision site. In case of bleeding is present add more sterile dressing and bandage in position, and report immediately to the nurse in charge or the doctor.

  • Special nursing care is given to patients as per operation and condition.

PERI-OPERATIVE CARE (Summary)

PRE-OPERATIVE:

  • Admission
  • Explanation to the patient about the nature of the surgery and the possible outcomes.
  • Informed Consent for admission and surgery.
  • Vital observations and other lab investigations, radiological investigations to get a baseline.
  • Preparation of the body and mind through counseling and continuous reassurance. This helps to allay anxiety as well.
  • Talk to the patient and answer questions of their concerns to reduce fear/anxiety.
  • Spiritual care if one so wishes; respective church leaders are allowed to come and see the patient.
  • A baseline Physical examination, e.g., weight, height, nutritional status, needs to be assessed prior.
  • Site preparation: involves marking/labeling, 48 hours shaving if hairy.
  • Removal of jewelry and rings.
  • Removal of dentures and prostheses.
  • Inserting an IV line.
  • Rehydration with IV fluids.
  • Administration of premedication drugs.
  • Perform required procedures like inserting NGT, catheterization, bowel irrigation.
  • Ensure enough rest and sleep.
  • Educate on anticipated activity post-operatively.
  • Starve the patient prior as per order (nil per os).
  • Make a post-op bed with all the necessary accessories required, e.g., oxygen, suction apparatus.

POST-OPERATIVE CARE:

  • Reception from theatre with all the necessary instructions.
  • Vital parameters monitoring.
  • Monitoring for bleeding, and signs of shock.
  • Admission to a warm postoperative bed from the theatre.
  • Intravenous infusion with fluids and prescribed drugs.
  • Fluid balance chart recording and monitoring.
  • Ongoing post-op medication.
  • Bowel and bladder care.
  • Rest and sleep.
  • Proper management of drainages, e.g., abdominals, etc.
  • Proper positioning to relieve pain.
  • Diet/nutrition.
  • Wound care.
  • Pain management.
  • Bed hygiene.
  • Body/skin hygiene.
  • Physiotherapy, e.g., breathing exercises.
  • Psychological care.

POST-OPERATIVE COMPLICATIONS:

  • Hemorrhage; can be primary or secondary.
  • Pain.
  • Shock.
  • Wound infection/sepsis.
  • Hypostatic pneumonia due to constant lying on the bed.
  • Delayed healing.
  • Paralytic ileus.
  • Adhesions.

Post-Operative Nursing Care Read More »

CARE OF THE PATIENT’S EYES

CARE OF THE PATIENT’S EYES.

Care of the patient’s eyes includes a range of procedures and practices aimed at maintaining the cleanliness, comfort, and health of the eyes.

It Involves:

  • Cleaning of the Eye: This includes removing debris, discharge, and crusting from the eyelids and eyelashes. It’s done gently using sterile wipes or cotton balls moistened with warm water.
  • Instillation of Eye Drops/Ointment: This is done to deliver medication directly to the eye, treating various conditions like infection, inflammation, dryness, or glaucoma.
  • Cold and Warm Compresses: These are used to reduce inflammation, calm irritation, or promote relaxation. Cold compresses are applied for injuries or swelling, while warm compresses are beneficial for dry eye or clogged tear ducts.
  • Eye Irrigation: This involves flushing the eye with a sterile solution to remove foreign objects, irritants, or excessive discharge.

Indications of Cleaning the eye

  • Patients with Eye Discharge: This can be a sign of infection, inflammation, or irritation. Cleaning the eye, instilling appropriate drops, and sometimes irrigation can help manage the discharge and promote healing.
  • Postoperative Care for Patients Following a Cataract Operation: This includes gentle cleaning of the eye, instillation of prescribed eye drops, and monitoring for signs of infection or complications.
  • Eye Care for the Unconscious Patient: This is crucial for preventing infections and maintaining eye health. It includes cleaning the eye, keeping the eyelids closed, and ensuring the eyes are protected from injury.
  • To Be Performed Prior to Instilling Eye Drops or Ointment: Cleaning the eye beforehand helps ensure that the medication is delivered effectively and avoids contamination.
  • Patients with Dry Eye Syndrome: Eye care practices can help manage symptoms by promoting tear production, lubricating the eye, and protecting the cornea.
  • Patients with Eye Allergies: Cleaning the eye and instilling antihistamine drops can help manage the symptoms of itching, redness, and watery eyes.
  • Patients with Foreign Body in the Eye: Eye irrigation with a sterile solution is essential to remove the foreign object and prevent damage to the cornea.

Aims/Purposes of Eye Care:

  • To prevent and treat infections: Cleaning and disinfecting the eye area helps reduce the risk of infections.
  • To alleviate symptoms and discomfort: Procedures like cold compressions, warm compresses, and eye irrigation can provide relief from pain, itching, and dryness.
  • To promote healing and recovery: Appropriate cleaning and medication can help facilitate healing after eye surgery or trauma.
  • To maintain optimal eye health: Regular eye care can help prevent eye diseases and preserve vision.
Cleaning of the Eye

Cleaning of the Eye

Objectives

  1. Identify the requirements for cleaning the eyes.
  2. Prepare the requirements for cleaning the eyes.
  3. Demonstrate the ability to clean the eyes.

Requirement

Tray containing:

  • Gallipot of cotton balls
  • Receiver
  • Clean/disposable gloves
  • Mackintosh and towel
  • Plastic apron
  • Gallipot of normal saline 0.9% or cooled boiled water

At the bedside:

  • Hand washing equipment
  • Screen

Procedure

Steps

Action

Rationale

1.

Observe general rules.

Promotes adherence to standards.

2.

Put the patient in a sitting up position.

To prevent the flow of solution to the healthy eye.

3.

Place protective mackintosh and towel in place.

To prevent soiling/wetting the patient’s clothes.

4.

Wash and dry hands and put on gloves.

To prevent cross infection.

5.

Stand at the right-hand side of the patient.

 

6.

Dip the swabs/cotton balls in the solution and bathe the eye in the following sequence: 

– Start from the healthy eye 

– Swab from the nasal to the temporal aspect, using the swab once and discard. 

– Use the dry swabs to dry the eye 

– Do the same for the other eye 

– Repeat the swabbing until the eye is cleared of all discharge.

Prevents contamination from entering the other eye. Prevent the spread of infection.

7.

Dry excess fluid with a dry swab.

Prevent the spread of infection.

8.

Thank and leave the patient comfortable.

Promotes a sense of well-being.

9.

Clear away.

Maintain the cleanliness of the environment.

10.

Document the procedure.

 
INSTILLATION OF EYE DROPS OINTMENT.

INSTILLATION OF EYE DROPS/ OINTMENT.

Instillation Of Eye Drops/ Ointment is the process of application of medication into the patients’ eyes.

Objectives

  1. Identify the requirements for instilling eye drops/ointment.
  2. Prepare the requirements for instilling eye drops/ointment.
  3. Instill the eye drops/ointment to the eyes.

Indications:

For Eye Drops:

  • To treat infections: Antibiotic eye drops are commonly used to combat bacterial infections like conjunctivitis (pink eye).
  • To keep eyes moist: Artificial tears or normal saline drops are used to lubricate the eye and relieve dryness, often prescribed after cataract surgery.
  • To anaesthetize the eye: Anaesthetic drops numb the eye surface, used for procedures like cataract surgery or foreign body removal.
  • To dilate the pupil: Mydriatic drops widen the pupil, facilitating eye exams or helping treat certain eye conditions.
  • To reduce inflammation: Steroid eye drops are used to reduce inflammation in the eye, often prescribed after eye injury or surgery.
  • To lower intraocular pressure: Glaucoma medications are often administered as eye drops to control eye pressure and prevent further damage.

For Eye Ointment:

  • To protect the vision of neonates: Prophylactic antibiotic ointment is routinely applied to newborns’ eyes to prevent infections.
  • To treat infections: Antibiotic ointments can be used to treat bacterial eye infections, often preferred for overnight treatment due to their longer-lasting effect.
  • To lubricate and soothe dry eyes: Ointments can provide a longer-lasting lubricating effect than drops, especially helpful for severe dryness.
  • To treat certain eye allergies: Steroid ointments can be used to reduce allergic inflammation.

Requirements

  • Patient’s medication chart.

Tray:

  • Prescribed eye drops/eye ointment
  • Gallipot of cotton balls
  • Receiver
  • Gloves
  • Eye pad in a sterile bowl
  • Strapping

At the Bedside:

  • Hand washing equipment

  • Screen

Procedure for eye drop

Steps

Action

Rationale

1.

Refer to general rules.

Promotes adherence to standards.

2.

Check the prescription.

Ensures correct administration of medicine.

3.

The patient may be seated or lying down for this procedure.

Provides easy access to the eye for instillation.

4.

Wash hands and put on gloves.

Prevents the spread of microorganisms.

5.

Clean the eyes as before.

Prevents entrance of microorganisms to the lacrimal duct.

6.

Place a folded swab on the lower lid up to the lash margin.

Absorbs medication that escapes from the eye.

7.

Instilling eye drops: Gently pull down the eyelid of the affected eye.

Exposes lower conjunctival sac.

8.

Request the patient to look up; hold the dropper close to the eye and drop the medicine according to the dose into the lower conjunctival sac.

To reduce stimulation of the blink reflex.

9.

Release the lower eyelid after the eye drops are installed.

 

10.

Request the patient to gently close the eye.

 

11.

Apply gentle pressure over the inner Canthus.

To prevent eye drops from falling over the inner Canthus to prevent systemic effects from the medicine.

12

Administering eye ointment:

– Gently pull down the lid

To expose the inner surface of the lid and conjunctival sac.

13

Squeeze a small amount (1.25cm) of ointment along the exposed sac from in outwards.

Promotes comfort and prevents trauma to the eye.

14

Instruct the patient to close the eyes.

The warmth helps to liquefy the ointment Prevents contamination and entrance of micro-organism into the eye.

15

Instruct the patient to roll the eyeball

Patient should keep the eye closed for a few minutes.

Allows even distribution of medication over the eye.

16

Thank and leave the patient comfortable.

Ensures patient’s comfort.

17

Clear away.

Ensures a clean environment.

18

Record treatment given on the chart.

Continuity of care and follow up.

General Principles – Application of Eye Ointment

  • Ointment may be prescribed in addition to drops. If both are prescribed, drops should be instilled first, followed by ointment after a 3-minute interval.
  • Ointment may be prescribed for structures other than the eye. This could include wounds on the lids, face, or eye socket.
  • Ointment may be prescribed for use after the first dressing. This might not happen for up to a week in some oculoplastic surgery cases.
  • If requested, visual acuity should be recorded before ointment is applied. This is because ointment clouds vision. Any existing ointment excess should be removed before taking the measurement.
  • A 5-mm strip of ointment should be applied to the inner edge of the lower fornix of the appropriate eye.
  • The patient should close his eye and remove excess ointment with a swab.
  • The patient should be advised that the ointment is likely to cause blurring of vision due to its viscous nature.
  • In the case of wounds on the lids, face, or eye socket, ointment should be squeezed directly onto the wound. It can be dispersed using a moistened swab. If the ophthalmic surgeon requests it, the wound or scar should be massaged using the ointment.

INSTILLATION OF EYE DROPS OINTMENT.

Procedure of Instillation of Eye Ointment

Steps

Action

Rationale

1.

Wash hands and prepare trolley and equipment in accordance with ANTT (Aseptic Non Touch Technique) principles.

Promotes adherence to standards.

2.

Check the patient identification band against the eye-drop medication chart.

Ensures correct patient identification and medication administration.

3.

Prepare the patient for the procedure and obtain consent, giving an explanation of the procedure including any side-effects of the medication.

Informed consent and patient understanding of the procedure.

4.

Assess the patient as before, including ensuring that the drops are not contra-indicated.

Ensures the medication is safe and appropriate for the patient.

5.

The patient should be seated.

Provides easy access to the eye for instillation.

6.

Wash hands or use alcogel.

Prevents the spread of microorganisms.

7.

Prepare equipment and place it in the tray, identifying key parts to be protected during the procedure; in this case, the tips of bottles.

Maintains aseptic technique.

8.

Check drops/ointment against the prescription.

Ensures correct medication is administered.

9.

Check the correct strength (%) of the drops against prescription.

Ensures correct dosage.

10.

Check drops/ointment have not expired. Check clarity of drops, i.e., the fluid in the bottle/minim must be clear and not discoloured.

Ensures medication is safe and effective.

11.

Check packaging/bottle seal is intact when first used.

Ensures sterility and safety of the medication.

12.

Identify any current allergy to the topical medications.

Prevents adverse allergic reactions.

13.

Ensure that the drops are instilled into the correct eye.

Ensures correct administration site.

14.

Examine the eye to be treated for the following: 

Redness not attributed to surgery or other known causes.

No stickiness or pain.

No deterioration of vision.

Allergies to the prescribed eye drops.

Assesses the condition of the eye to avoid complications.

15.

Check no contact lens in situ unless advised to the contrary by the doctor.

Prevents interference with medication absorption and eye health.

16.

Remove gloves, clean hands with alcohol gel and reapply non-sterile gloves.

Prevents contamination and maintains hygiene.

17.

Open packaging, ensuring key parts remain protected. NB: You may need to open additional packaging if the eye needs cleaning prior to drop instillation, in which case you should proceed to eye cleaning first.

Maintains aseptic technique.

18.

Instruct the patient to slightly tilt the head back and ask the patient to look up. NB: Before using any bottle of eye drops, shake the bottle first.

Facilitates easy access to the eye and proper medication distribution.

19.

Instill only one drop into the lower fornix towards the outer canthus or squeeze 5 mm of ointment along the lower fornix towards the outer canthus. NB: Ointment must only be applied after prescribed eye drops.

Ensures correct medication application.

20.

Ask the patient to gently close his eyes, counting slowly to 60. This helps to minimize systemic absorption.

Promotes proper absorption and effectiveness of the medication.

21.

Wipe away any excess drops/ointment, taking care not to wick away drops from the eye.

Maintains patient comfort and ensures proper dosage remains in the eye.

22.

If further drops are prescribed, wait an interval of 3 minutes before carrying out the procedure. Apply alcogel to hands before instilling the next eye drop.

Prevents contamination and ensures effectiveness of multiple medications.

23.

Make the patient comfortable; patients usually appreciate being given a tissue to dab their cheeks.

Ensures patient comfort and cleanliness.

24.

Dispose of clinical waste, cleanse hands, and then clean the tray.

Maintains a clean and safe environment.

25.

Cleanse hands and document the procedure in the case notes and/or drop chart.

Ensures proper record-keeping and patient safety.

WARM EYE COMPRESS.

WARM EYE COMPRESS.

A warm eye compress involves applying a warm, moist cloth or compress to the eye area. 

  • Soothe and relax the eye muscles: The warmth helps to relax the eye muscles, which can be helpful for reducing eye strain and fatigue.
  • Increase blood flow to the area: The warmth dilates blood vessels, increasing blood flow to the eye area, which can promote healing and reduce inflammation.
  • Loosen eye secretions: Warmth can help loosen mucus and other secretions in the eye, making them easier to remove.

Indications for Warm Eye Compresses

  • Pain Relief: Warm compresses can help reduce discomfort and pain in the eye area.
  • Reduce Inflammation: The warmth helps to decrease inflammation and swelling in the eye.
  • Improve Medication Absorption: Warm compresses can enhance the absorption of eye drops or ointments.
  • Promote Drainage: Warmth helps to loosen and drain secretions, which can be beneficial for superficial infections.
  • Dry eye: Warmth can help to stimulate tear production and lubricate the eye surface.
  • Stye (hordeolum): A stye is a painful red bump on the eyelid caused by a bacterial infection. Warm compresses can help to bring the stye to a head and promote drainage.
  • Blepharitis: This is a common eye condition that causes inflammation of the eyelids. Warm compresses can help to loosen debris and reduce inflammation.
  • Conjunctivitis (Pink eye): This is an infection of the conjunctiva, the thin transparent membrane that lines the inside of the eyelid and covers the white part of the eye. Warm compresses can help to soothe inflammation and promote drainage.
  • Eye strain: Warm compresses can help to relax eye muscles and relieve eye strain caused by prolonged computer use or reading.
  • Meibomian Gland Dysfunction (MGD): This condition involves a blockage of the oil glands in the eyelids, causing dry eye and other symptoms. Warm compresses can help to loosen and drain the oil glands.

Requirements

Tray

Bedside

Bowl with warm water

Screen

Sterile water or normal saline

Hand washing apparatus

Mackintosh cape and towel/dressing mackintosh

 

Sterile bowl

 

Cotton swabs

 

Receiver

 

Procedure

Steps

Action

Rationale

1

Identify the eye to be treated.

Ensure the correct eye to prevent error.

2

Follow the general rules.

Promote adherence to standards.

3

The patient may be seated or lying down for this procedure.

To ensure comfort for the patient.

4

Place the bowl with solution in a bowl of warm water.

Cold application is very uncomfortable for the patient.

5

Wash dry hands and put on gloves.

To prevent the chance of cross infection.

6

Place the swab in the warm solution (37°-41°C).

To improve circulation and relieve pain.

7

Squeeze out the excess solution.

To reduce the chance of scalding the patient and wetting patient’s clothes.

8

Instruct the patient to close the eye. Gently apply the swab on top of the affected eye.

To promote patient’s safety and prevent skin damage.

9

Change the compress every 2 minutes for the prescribed length of time.

To maintain a constant temperature for the duration of therapy.

10

Use a dry swab to clean and dry the eyes.

Promote patient’s comfort.

11

If required apply eye drops/ointment.

To prevent infection.

12

Thank and leave the patient comfortable.

Promotes patient’s well-being.

 

COLD EYE COMPRESS

Cold compress is placing of a cold compress/pack over the affected area or eye
to relieve discomfort.

Indications of Cold compress

  • Reduce inflammation: Cold compresses constrict blood vessels, reducing inflammation and swelling.
  • Relieve pain: The coldness helps numb the affected area, reducing pain and discomfort.
  • Reduce bleeding: Cold compresses can help stop minor bleeding by constricting blood vessels.
  • Control bruising: Applying cold compresses immediately after an injury can help reduce bruising by minimizing blood pooling.
  • To reduce swelling or bleeding: Cold compresses can help reduce swelling and bleeding in the eye area by constricting blood vessels.
  • To ease periorbital discomfort: Cold compresses can help ease pain and discomfort around the eye area.
  • To relieve itching: The coolness of the compress can help reduce itching in the eye area.

Requirements

Tray

  • Ice cubes/chips
  • Solution: sterile water or normal saline solution
  • Mackintosh and towel/Dressing mackintosh
  • Strapping
  • Cotton swabs
  • Clean gloves

At the bedside

  • Screen
  • Hand washing apparatus

Procedure of cold compress

Steps

Action

Rationale

1

Follow the general rules of nursing procedure.

Prevent solution from over the nose and into the eye.

2

Identify the eye to be treated.

To prevent errors.

3

The patient should lie down for this procedure.

To prevent the solution from wetting the patient’s clothes.

4

Position the mackintosh and towel to protect the patient’s clothes.

To prevent wetting the patient’s clothes.

5

Place the swab in the bowl of ice chips (18-27°C).

To make it easy to apply and provide comfort.

6

Wash dry hands and put on gloves.

To prevent infection.

7

Place the moist swab over the affected closed eye.

The swab helps to conduct the cold from the ice pack.

8

After 15-20 minutes, remove the cold compress.

To prevent skin change this can occur from vasoconstriction.

9

Use a dry swab to clean and dry the patient’s face.

To ensure comfort.

10

If required apply eye drops/ointment.

To prevent/treat infection.

11

Thank and leave the patient comfortable.

To ensure comfort.

12

Clear away and document procedure.

To ensure proper records are kept.

Eye Irrigation

Eye Irrigation

Eye irrigation involves flushing the eye with a sterile solution to remove foreign bodies, irritants, or discharge. This process helps cleanse the eye, reduce inflammation, and improve visual clarity.

Eye irrigation is the washing of the conjunctiva sack with a stream of fluid(water). The gentle flow of the irrigation solution washes away the offending substance from the eye. The solution is typically sterile and isotonic to minimize irritation.

Purpose/Aims of Eye Irrigation:

  • To remove foreign bodies from the eye: This includes dust, dirt, small particles, or insects that may have entered the eye.
  • To remove chemicals which have been accidentally splashed into the eye(s): This includes chemicals, smoke, fumes, or allergens that may cause irritation.
  • To washout discharge: This includes mucus, pus, or other secretions that may accumulate in the eye.
  • Reduce inflammation: The flushing action can help reduce inflammation and swelling.
  • Improve visual clarity: Removal of foreign objects or discharge can improve vision.
  • Before administration of medication: Irrigation can help prepare the eye for medication application.
  • In preparation for eye operations: Irrigation can help cleanse the eye before surgery.

Indications for Eye Irrigation:

  • Foreign body sensation: If a patient feels something in their eye, such as a speck of dust or a small insect.
  • Chemical or irritant exposure: If the eye has come into contact with a chemical or irritant.
  • Discharge or secretions: If there is excessive discharge or secretions from the eye.
  • Eye infections: In some cases, eye irrigation can help remove infectious material and reduce inflammation in certain eye infections.

Requirements

Tray-sterile

  • Irrigating solution-Normal saline at 37°C or plain boiled cooled water(sterile).
  • Sterile gloves, patient’s towel
  • Lid retractor
  • Litmus paper
  • Undine or any small container with a pouring spout e.g. feeding cup, bulb syringe or Sterile irrigation set
  • Eye pad/waterproof pad
  • Gallipot of cotton balls or facial tissues
  • 2 receivers, mackintosh cape and towel/dressing mackintosh
  • Boric acid 2 to 4 %
  • Gallipot of cotton

At the bedside

  • Wash hand equipment
  • Screen

Eye Irrigation

Procedure

Steps

Action

Rationale

1

Follow the general rules for all nursing procedures.

Promotes adherence to standards.

2

Have the patient sit or lie down with the head tilted toward the side of the affected eye. Protect the patient and the bed with a dressing mackintosh or waterproof pad and a towel.

Gravity helps the flow of solution away from the unaffected eye and from the inner canthus of the affected eye toward the outer canthus.

3

Put on gloves. Clean the eye as before.

–

4

Place the curved part of the receiver at the cheek on the side of the affected eye to receive the irrigating solution. If the patient is sitting up, request the patient to hold the receiver.

Cavity aids the flow of solution.

5

Expose the lower conjunctival sac and hold the upper lid open with the non-dominant hand.

To avoid injury to the conjunctival sac and prevent reflex blinking.

6

Hold the irrigator about 2.5 cm from the eye. Direct the flow of the solution from the inner to the outer canthus along the conjunctival sac.

This minimizes the risk of injury to the cornea and prevents the spread of infection from the eye to the lacrimal sac, lacrimal duct, and the nose.

7

Irrigate until the solution is clear or all the solution has been used. Use only sufficient force gently to remove secretion from the conjunctiva without touching any part of the irrigating equipment.

To prevent injury to the tissues of the eye, as well as the conjunctiva, and promote comfort for the patient.

8

Tell the patient to close the eye and move the eye periodically.

Helps to move the secretion from the upper to the lower conjunctival sac.

9

Dry the area after irrigation with cotton balls. Offer the towel to the patient if the face and neck are wet.

To provide comfort.

10

Remove gloves and wash your hands.

–

11

Make the patient comfortable.

–

12

Document the procedure or findings.

–

13

Clear away.

–

Points to remember

  •  For chemical burns, irrigate each eye for at least 15 minutes with normal saline solution to dilute and wash out the harsh chemicals.
  •  If the patient cannot identify the specific chemical, use litmus paper to determine if the chemical is acidic or alkaline or to be sure the eye has been irrigated adequately.
  • When irrigating both eyes, ask the patient to tilt his head towards the side being irrigated to avoid contamination.
  • An irrigation fluid  may be pre-packed in a disposable set for use or a sterile 50ml syringe may be used.

CARE OF THE PATIENT’S EYES Read More »

Contact us to get permission to Copy

We encourage getting a pen and taking notes,

that way, the website will be useful.

Scroll to Top

Terms and Conditions - Privacy Policy