11. The Child With a Sensory Alteration

Question 1

Review of the Eye

* Attached to the skull by 6 accessory muscles

* Cranial nerves __, __, __, __, and __ all affect the eye

* Cornea and sclera make up the eye’s outer layer

* Choroid, lens, and iris make up the middle layer

* __ is known as the inner layer

Answer 1

2, 3, 4, 5, and 6

Retina

Question 2

Review of the Ear

* Structure and function

> Divided into 3 parts

> Auricle and ear canal comprise the outer ear

> Separated from the middle ear by the tympanic membrane

> Bones of hearing make up the middle ear (hammer, anvil, and stirrup)

> Nerve endings that conduct sound reside within the inner ear

Answer 2

Question 3

Neonatal Development

* Sense organs develop quite early in gestation

> Eyes begin to develop at 22 days

Critical period __-__ days of gestation

> Ears begin to develop during the 3rd week

Critical period occurring at __-__ weeks of gestation

* Sensitive to teratogens

* Any interference in development can result in later sensory alterations

Answer 3

22-50 days

4-6 weeks

Question 4

Speech Development

* Fetus is capable of hearing during the ___ trimester

* Able to hear voices and the mother’s heartbeat

* Adequate hearing is essential for the development of speech

* Coo and vocalize from birth to 4 months

* Babbling begins at 4-6 months

* Followed by receptive and expressive language development

* Hearing impairment can interfere with speech development

Answer 4

second

Question 5

Eye Assessment

* Inspection, palpation, and evaluation for visual acuity and extraocular muscle function

* Obtain a family history of eye disorders

* External eye
> Position and placement (based on inner canthi)
> Inspect eyebrows for symmetry in hair growth and eyelashes for even distribution
> The punctum tear duct is palpated for obstruction
> Eyelids inspected for color swelling discharge in lesions
> Conjunctiva examined - clear with a pink color
> Inversion of the upper eyelid is not normally done

Answer 5

> Sclerae - white
> Cornea - clear, transparent and very sensitive
> Iris is round and pigmentation is unique
> Pupils round regular and equal in both eyes

> Pupillary light reflex - dark room - shine light - pupils constrict

Question 6

Binocular Vision & Strabismus

* Three tests used to test for strabismus which is the abnormal or incomplete development of binocular visual alignment

> The corneal light reflex (Hirschberg)

* First by shining a light directly on to the iris from a distance of approximately 16 inches

* The reflection of the light should appear in exactly the same spot in both eyes

* If the light falls off center in one eye the eyes are malaligned

Answer 6

Question 7

> Field-of-vision test

* The six cardinal fields of vision are tested by holding the child’s chin so that the head does not move and asking the child to follow a puppet or familiar object held approximately 12 inches away from the face as the object is moved to each of the 6 cardinal positions

Answer 7

* The eyes should track in a parallel manner to each position

Question 8

> Cover/uncover (alternate cover) test

* Extraocular muscle function evaluates three cranial nerves: __, __, and __

* Used to detect deficits in binocular vision by interrupting fusion of the eyes as they gaze at a fixed object

* One eye is covered while the other eye is not; have the child stare straight ahead - a steady fixed gaze is maintained by the uncovered eye

* Next uncover the eye and observe for any movement it should continue to stay straight ahead

* Movement in either eye suggests muscle weakness

Answer 8

7, 9, 3

Question 9

Visual Acuity Tests

> Visual acuity testing should begin for all children at the age of ___

> The chart chosen is determined by the child’s age and development

> The US preventative service task force recommends screening for all children for visual impairment at least once between the ages of __ and __ to detect presence of amblyopia or its risk

> Types of eye charts
→ Snellen chart or Tumbling E
→ HOTV chart
→ Lea chart
→ Ishihara chart

Answer 9

3

3-5

Question 10

Snellen Chart

> Standardized chart with graduated letters for testing far vision of children at 20 feet

> Used with children older than 6

> Both eyes are tested together first and then each eye is tested separately

> If a child wears corrective lenses their procedures should be repeated with the corrective lenses on

Answer 10

> Example: child correctly identifies the letters on the line labeled 40 feet means that child can see at 20 what the average child can see at 40 feet - so their vision is at 20/40

Question 11

> Visual acuity changes with age and varies according to the test used

Normal ranges are as follows

Birth

* Fixates on objects 8 to 12 inches, 20/100 to 20/150

Four months

* 20/50 to 20/80

Answer 11

One year 20/40 to 20/70

Four years 20/40 to 20/50

Five years 20/20 to 20/30

Question 12

Tumbling E

> Used in children older than 3

Answer 12

Question 13

HOTV Chart

> A standardized chart with the letters HOTV in graduated sizes

> Designed for use at 10 feet with children 3-6 y.o.

> The letters HOTV are presented at a distance and the child points to the corresponding letters on the card resting on their lap

> One eye is covered, and the child is instructed to match the letters on the card with a chart at 10 ft using the uncovered eye

Answer 13

> Screening is begun at 20/50 line for children younger than 4 years, the 20/40 line for children 4 to 5 years and the 20/30 line for older children

> The child passes the screening if they correctly identify 4 of the 5 symbols

Question 14

LEA Chart

* A chart with four different symbols

* Use for preschool age children

* Designed for use at 10 feet

Answer 14

Ishihara Chart

* A series of polychromatic cards with a pattern of dots printed against a background of many-colored dots

* Designed to test for color vision between ages 4 and 6

Question 15

Disorders of the Eye

* Blocked lacrimal duct

* Refractive errors

* Color deficiency

* Amblyopia

* Strabismus

Answer 15

* Glaucoma

* Cataract
> Congenital glaucoma
> Secondary glaucoma

Question 16

Blocked Lacrimal (Tear) Duct

* Characterized by excessive tearing (___) and crusting on the eyelids on awakening

* May note a small mass below the inner aspect of the eye

* Treatment
> Massaging the duct
> If persists may need surgical opening after the age of 1

Answer 16

epiphora

Question 17

Blocked Lacrimal (Tear) Duct - Nursing considerations

* Assess mucoid drainage
> White or clear
> If infected, drainage can be green or yellow - treated with antibiotic eye drops or ointment

Answer 17

* Teaching parents on proper technique for lacrimal massage
> Washing hands thoroughly

> Place index finger over the lacrimal duct and milking or gently massaging the duct in an upward motion

> Monitor for S/S of infection

Question 18

Refractive Error

* Refractive errors cause vision disturbances from alterations in the path of light rays through the eye

Answer 18

Types of refractive errors

Question 19

___ also known as near-sightedness

> Ability to see close objects more clearly than those at a distance

> Children may have difficulty seeing the blackboard or TV clearly, they may squint, tilt their head or hold books closer to the eyes - they may have decreased attention span and associated poor school performance

> Treated with biconcave lenses and may require these to be changed every 1-2 years as the child grows

Answer 19

Myopia

Question 20

___

* Unequal curvature of the cornea or the lens which causes the light rays to bend in different directions

* May coexist with myopia or hyperopia

* Symptoms may be similar to myopia

* Treated with a special lens to compensate for the unequal curvature of the cornea

Answer 20

Astigmatism

Question 21

___ also known as farsightedness

* Ability to see distant objects more clearly than those close up

* Usually normal for a child to be hyperoptic until approximately the age of 7 years

* Able to accomodate and see clearly so need no correction at a young age

* Strabismus or amblyopia can develop from a prolonged hyperopia
> would need a correction with convex lenses

Answer 21

Hyperopia

Question 22

Refractive Error

___ - light rays focus on the retina

___ - light rays focus in front of the retina

___ - light rays focus on more than one point (unequal refraction of light in different meridians)

___ - light rays focus behind the retina

Answer 22

Normal eye

Myopia

Astigmatism

Hypermetropia

Nurses play important role in assessing these disturbances

School nurses should test children as young as 3 years of age

Question 23

Color Deficiency (or Color Blindness)

* Occurs 8% of population and 20x more prevalent in males

* Genetic alteration in X chromosome - inability to discern colors with certain groups - red, blue, green

* Testing routinely done in preschool boys

* Pseudoisochromatic test - Ishihara test - used for children who cannot read

Answer 23

* Cannot be cured - focus on adaptive and supportive measures

* Safety major concern as child gets older - driving and distinguishing traffic signals

Question 24

___

“lazy eye”

* Seen in 2-4% of children; most frequent causes of diminished vision in children

* Frequently associated with strabismus as well as with other congenital cataract and severe refractive errors

* Occurs when both eyes are unable to focus simultaneously so the brain suppresses the image from the deviating eye to avoid double vision diplopia

Answer 24

Amblyopia

Question 25

Amblyopia - Treatment

> Penalization (blurring)

* Atropine
> Atropine cycloplegic agent is used to paralyze the ciliary muscles to dilate the eye which leads to blurring the vision in the stronger eye

* Occlusion
> Patch - MUST BE WORN FOR THE EXACT PRESCRIBED TIME

Answer 25

The goal is to alter or obscure vision in the stronger eye to force the child to use the amblyopic eye

Question 26

Strabismus

* Occurs when the eyes are not aligned because of lack of coordination of the extraocular muscles

* Occurs in about 4% of children younger than 6 years of age more prevalent in premature infants - normal in young infants but not over 3 months of age

Causes

> Muscle imbalance, paralysis of the extraocular muscles, brain tumor, myasthenia gravis, infection, genetic abnormalities, neuromuscular disease, exposure to teratogens, trauma

Answer 26

Diagnosis

> The corneal light reflex test, simultaneous red reflex test, cover/uncover test, and alternate cover test can be used to diagnose strabismus

Suspect strabismus? If a child reports frequent headaches, squints or tilts their heads to see

Question 27

Treatment includes special corrective lenses, vision therapy, surgery, or pharmacologic therapy

The goal is to initiate this therapy as soon as possible

Answer 27

* In severe cases surgery may be indicated to realign the weakenend muscles and should be performed before the child is 2 years of age

Question 28

?

* Is a condition in which intraocular fluid pressure of the eye is increased - can lead to atrophy of the optic disc and ultimately blindness

* Is a significant cause of blindness in children

Answer 28

Glaucoma

Question 29

Types of glaucoma

> Congenital glaucoma also called infantile glaucoma occurs during the first 3 years of life

> Secondary glaucoma usually occurs after 3 years of age or is acquired from an infection, trauma or cataract removal

Answer 29

S/S

> Excessive tearing, light sensitivity, blepharospasm (which is a muscle spasm caused by involuntary closing of the eyelid), and enlargement of the globe and cornea

Question 30

Treatment

> Surgery (preferred) - the goal of the surgery is to increase the outflow of the aqueous humor from the interior chamber by correcting the structural abnormality causing the decreased outflow or to create different route for the outflow

Medications - cholinergic agents, beta-adrenergic blocking agents, or adrenergic agents - used after surgery to maintain a low intraocular pressure

Answer 30

CAUTION WITH SYSTEMIC EFFECTS

Question 31

Glaucoma: Treatment - Postoperative Nursing Care

* Monitor for s/s of increased intraocular pressure (pain, nausea/vomiting, increased inflammation) - AVOID CRYING, N/V

* Administering any ordered medications like miotic eye drops - used to constrict the pupils and antibiotic ointments or eye drops

Question 32

A ___ is an opacity or loss of transparency of the lens

Causes:
> Inherited tendency (autosomal dominant trait), infection (rubella), trauma or a metabolic imbalance

S/S
> Cloudiness of the lens
> Nystagmus and strabismus

Treatment includes surgical removal of the opaque lens within 8 weeks of age

Answer 32

cataract

Question 33

Cataract

* Postoperative care is mostly directed to avoid increased intraocular pressure
> Measures like preventing coughing, straining, vomiting and touching the surgical site are important

* Patch or hard shield - to prevent injury

* Head of bed should be elevated - to avoid edema

* Assess s/s of infection - fever, drainage, redness

Answer 33

Medications - antibiotics, mydriatics, and steroids

Postoperative teaching parents:
> How to insert, remove, and care for the child’s contact lens
> s/s of infection and intraocular pressure
> Adhering to the prescribed patching regimen and importance of returning for follow-up visits

Question 34

Eye Surgery Nursing Considerations

* Orientation to environment to ensure SAFETY
> Restraints are used as a last resort to prevent injury
> Encourage the parent to keep siderails up at all times

* Encourage use of eyepatch or shield

* Encourage parents to stay with child to avoid rubbing the eyes

Answer 34

* Monitor for s/s of intraocular pressure and infection
> Antiemetics to prevent vomiting

* Always approach child in a CALM, SOOTHING MANNER to avoid crying

* Administer antibiotics as ordered or prophylactically

Question 35

Eye Surgery Nursing Considerations

* Monitor for pain
> Monitor the child frequently (every 2-4 hours while awake)

* Use appropriate pain scale
* Physiological signs of pain (increased pulse, restlessness, inability to sleep, or inability to play)
* Pain can increase anxiety and restlessness and can lead to increased intraocular pressure

Answer 35

* Administer pain medications as ordered - helps decrease the child’s need to rub or touch the eyes

* Provide nonpharmacological pain relief measures like ice packs, moist heat; use distraction like music or stories

Question 36

Eye Infections

___

> “Pink eye” - inflammation of conjunctiva

S/S - itching, burning, light sensitivity, photophobia, scratchy eyelids, redness, edema, and discharge

Causes - allergy or infection (virus or bacteria) and in older children also trauma

Answer 36

Conjunctivitis

Question 37

___ ___

> Usually within 1st 24 hours - caused by Chlamydia

* After 1st 24 hours may be related to infection or blocked lacrimal duct

Treatment
> Antibiotic or antiviral eyedrops or ointments
> Antihistamines (if related to allergies)
> Severe cases steroid eyedrops

Answer 37

Ophthalmia neonatorum

Question 38

Conjunctivitis - Teaching

* Cleanse eye prior to med administration
> Parent may have to remove crusted material from the eye with cotton balls soaked in warm water
> Always teach the parent to wipe from the inner to the outer aspect of the eye, using new cotton ball for the other eye

Answer 38

* Bacterial or viral conjunctivitis is extremely contagious so the nurse must teach infection control measures which includes good hand washing, not using towels or washcloths, sharing medication (eye drops should never be shared and the tip or dropper of the ointment tube should not touch the child’s eye or eyelid)

WASH HANDS - extremely contagious

* If child has purulent conjunctivitis they should not be going to school or daycare until 24 hours after the antibiotics had started

Question 39

___ ___

> Caused by an infection of the soft tissues of the orbit which can result from trauma or related to a sinus infection

S/S

> Severe eyelid edema, erythema, an anteriorly displaced eye, decreased or absent vision, increased intraocular pressure and pain
> The child may be febrile with an elevated WBC count

Answer 39

Orbital cellulitis

Question 40

Diagnosis

> Computed tomography (CT) scan of eye and brain confirms diagnosis, assesses complications and assists with developing treatment plan

> Blood cultures done for appropriate antibiotic (vancomycin or ceftriaxone)

Answer 40

Treatment

* An emergent condition that requires aggressive intravenous (IV) antibiotics

* Analgesics

* Usually admitted to hospital for close observation due to rapid progression to systemic disease - which can spread to optic nerve to brain and cause meningitis and blindness

Question 41

Nursing care

* IV therapy

* Monitor s/s that may indicate infection is spreading - neurologic assessment

* Assess pain - apply heat 4x/day and administer prescribed analgesics

Answer 41

Question 42

Corneal ulcer

* Causes
> Ocular infection resulting from trauma but may also be caused by extended use of soft contact lenses, surgical procedures and viral infection of eye (herpesvirus type 1)

S/S
> Pain, tearing, purulent drainage and blurred vision

Answer 42

Treatment
> Aggressive antibiotic therapy with a broad-spectrum antibiotic until cultures are completed

> Fluoroquinolones: ciprofloxacin, ofloxacin, norfloxacin

> Systemic acyclovir may be used if caused by herpesvirus infection

Question 43

Corneal abrasion

> Scraping or tearing of the cornea by foreign bodies, contact lenses, paper, or fingernails

S/S
> Light sensitivity, pain, excessive tearing and decreased vision

Diagnosis - fluorescein dye to highlight injury

Answer 43

Treatment

* If small abrasion - antibiotic ointment of drops 4x/day for 1-2 days and then follow-up

* If big abrasion or suspicion of penetrating injury, refer to ophthalmologist and a patch x24 hours and then eye is reexamined

Teaching is very important
> Do not rub eye
> Adherence to antibiotic therapy
> Eye patch should not be removed for the first 24 hours

Question 44

Traumatic Eye Injuries

* Subconjunctival hemorrhage
> Red areas beneath the conjunctiva result from coughing, N/V, or straining

> Resolve spontaneously within 2-3 weeks and require no treatment
→ Parents need reassurance

> Hemorrhages may also occur with non-accidental eye injury as in the case of child abuse - shaken baby syndrome

Question 45

?

* Hemorrhage that results from a blow or penetrating injury to the eye

S/S
> Recent history of injury, pain, light sensitivity, decreased vision, presence of floaters and excessive tearing, sleepiness

Answer 45

Hyphema

Question 46

* If there is no known history of injury the child should also be assessed for bleeding disorder, anticoagulant therapy, renal hepatic disease, retinoblastoma or child abuse

Answer 46

* Any penetrating injury to the eye is an emergency - eye should immediately be covered with a sterile dressing or shield

Question 47

Treatment

* Restricted bed rest with head elevated 30-40°

* Sedation and protective shielding of the eye

* TV viewing may or may not be allowed, reading or other close-up activities are not allowed

* Medications such as steroid eyedrops, antifibrinolytic eyedrops, antiglaucoma medications, and cycloplegic eyedrops (atropine)

Answer 47

* Aspirin and nonsteroidal anti-inflammatory medications are contraindicated

* Careful assessment is required - secondary hemorrhage or a rebleed, increased intraocular pressure

* Frequent reorientation to environment is important for safety

Question 48

Chemical splashing

* Infective, hot or corrosive liquid splashes into eye

* Burns of eye are OCULAR emergency

* Common household items include bleach, ammonia, drain or oven cleaner

* If chemical is alkaline - irrigation may continue for several hours because the damaging action of alkaloids can be prolonged

* May need to anesthetize the eye prior to irrigation to facilitate irrigation

Answer 48

* Initial care - irrigation with water or saline
> Mild burn - irrigate for at least 30 minutes using at least 2 L of irrigant

> Severe burn - continue irrigating for 2 to 4 hours or with at least 10 L of irrigant

* Check pH periodically (7.0-7.3)

* Referral to ophthalmologist is necessary

* Oral antibiotics and analgesics

Nursing care focuses on prescribed medical treatments, comfort measures, and eye injury prevention

Question 49

The Child with a Visual Impairment

* Orient the child to the hospital environment by emphasizing spatial relations

* Never touch the child without identifying yourself and explaining what you plan to do

* When describing the environment, use familiar terms; avoid mention of color

* Remember that parents are often the best source for communication

* Identify noises for the child

Answer 49

* Frequently orient the child to time and place

* Keep all things in the same location and order

* Provide detailed explanations and allow the child to progress through care in steps to learn the order

* Allow as much control as possible

* Supervise the child and counsel parents to supervise the child as needed

Question 50

Types and Etiology of Hearing Loss & Associated Treatments

Mixed

Combination of ___ and ___ loss

Answer 50

conductive; sensorineural

Question 51

?

* Result of damage or malformation of the inner ear

* Hearing loss is usually permanent

* Hearing aids

* Infants and young children often do better with ear level hearing aids

Answer 51

Sensorineural

Question 52

?

* Result of damage to the conduction system between the auditory nervous system and the cerebral cortex

Answer 52

Central

Question 53

?

* Outer or middle ear affected by damage, inflammation, or obstruction

* Blockage may be related to excessive cerumen (wax), foreign object, perforated tympanic membrane, or otitis media

* Hearing loss can be temporary or reversible

Answer 53

Conductive

Question 54

Hearing Screening

* Most of the times hearing loss is only suspected when it affects academic performance

* So AAP recommends screening using the CDC’s 1, 3, 6 guidelines:

> Screening for hearing loss by 1 month of age

> Identification of hearing loss and referral to audiologist by 3 months of age

> Initiation of early intervention for documented hearing loss by 6 months of age

Answer 54

The AAP also recommends:

* Newborn screening followed by annual hearing risk assessment up to age of 4 years

* Formal screening from 5-7 years

* Alternating screening with risk assessment through middle childhood

Question 55

Risk factors indicating the need for hearing screening

* Parental caregiver concern

* Family history of hearing loss

* In utero exposure to infection

* Craniofacial abnormalities

* Syndromes associated with hearing loss

Answer 55

* Neonatal intensive care unit for more than 5 days

* Post-natal infection

* Trauma

* Exposure to excessive noise

* Chemotherapy or other medications associated with hearing loss

Question 56

Hearing Tests Used for Infants

Auditory brainstem response

* Uses electrodes placed on the infant’s head to record brain wave activity

* Brainwave measurement is compared with the brain wave measurement from a normal infant

* This test takes 10 to 60 minutes to adminster

Answer 56

Evoked otoacoustic emissions

* Assesses the integrity of the inner ear structures by recording sounds generated by the inner ear

* It cannot assess the degree of hearing loss but can assess whether hearing is present

* An ear probe containing a sound transmitter and microphone is attached to a computer and placed in the ear

* Emissions are displayed on a computer screen and these emissions are present in infants who can hear at 20 decibels but not present in infants who hear only at 30 decibels or higher

* This test takes approximately 5 minutes to administer

Question 57

Caring for the Child with a Hearing Loss

* Assess hearing at each well child visit

* Note infant’s response to bells, rattles, clapping of hands or horns held approximately 12 inches from the ear
* Older children can be asked to repeat whispered words or phrases or listen for ticking watch

* Begin audiometry testing at 3 years of age or younger in a cooperative child
* Assess language skill development
* Encourage hearing aid use
* Make sure the hearing aid is in place before speaking to the child
* Look directly at the child’s face to enhance lip reading

Answer 57

* Speak clearly, slowly and eliminate background noise

* Have the child’s complete attention before beginning to speak

* Use visual aids to assist in communication like pictures, hands, and written messages

* Teach parents to avoid exposure to loud noises

* Advise teens to decrease exposure to loud rock music and to turn off and turn down music volume

* Use basic sign language or an interpreter when necessary

Question 58

Language Disorders

* Until 10 to 12 months of age child is considered prelingual which means that the sounds the child makes have no direct meaning or connection to future language

* Sounds or practice of a learn skill

* Before 6 months of age infants make few sounds other than crying

* 4 to 6 months of age they enter the babbling phase

Answer 58

* First words appear approximately 10 to 12 months of age for sentences appear 18 months of age

* By two years of age most children have at least 50 words spoken vocabulary

Question 59

Language disorders may be related to genetic influences, infection, trauma, autism, hearing loss, and other etiologies

Types of language disorders:

___ disorder

> Child has a decreased ability to comprehend language

Answer 59

Receptive

Question 60

Expressive disorders

* Child cannot express thoughts through speech

3 types

___ disorder: an alteration in the way words are pronounced
> Most common type of speech defect

> May be caused by neuromuscular or structural abnormalities of nose, mouth, or throat

Answer 60

Articulation

Question 61

__ __ __ __ : an alteration in pitch and intonation, resulting from a medical condition such as cleft palate

Answer 61

Disorder of the voice

Question 62

___ disorder: an interruption in the flow of normal speech, including stuttering and lisping

> If stuttering persists beyond age 5, the child should be referred for speech evaluation

Answer 62

Fluency

Question 63

Which period of gestation is most critical for the development of sensory organs?

A. 1-2 weeks

B. 10-12 weeks

C. 4-6 weeks

D. 18-24 weeks

Answer 63

Answer: C

4-6 weeks