Np 615 Module 2, Eye, Ars, Nose, Throat

Front 1

How do you tell if the pain in eye is coming from eye surface or deeper surrounding tissues?

Back 1

A drop of local anesthetic in the conjunctival sac alleviates the pain from superficial abrasion and foreign body, but not pain from deeper structures.

Front 2

When should an eye problem be referred?

Back 2

always assess visual acuity; acute problems with vision require referral. The rare exception to this rule is in the case of chemical splash, your priority then moves to immediate irrigation

Front 3

What to warn patients about with locla anesthetic in the eye?

Back 3

be sure the patient does not continue to rub the eye, as the decreased sensation can allow for a great deal of damage

Front 4

What items to cover when do a history of an ocular problem?

Back 4

1.Onset
2.Duration of symptoms
3.Change in vision (acute or chronic)
4.Photophobis
5.Pain
6.Mechanism of injury
7.Use of contact lenses
8.History of eye surgery
9.Current medication
10.Recent exposure to new cosmetics, deodorants or persons with eye infection
11.Systemic complaints (fever, rash, genital discharge)

Front 5

What is included in routine physical exam of eye?

Back 5

1.Determine visual acuity of each eye with corrective lenses if normally worn. If the eye is painful instill a drop of topical anesthetic first. Do not forget visual acuity. It is a medico-legal necessity. Be sure your staff knows that all eye complaints must have this done and documented.
2.Inspect lids and palpebral conjunctiva.
3.Examine perioribital areas (preauricular lymphadenopathy, cellulitis)
4.Test extraocular muscle mobility (to check for paretic muscles and double vision.
5.Inspect cornea for abrasions, haziness, ulcerations, dendrites (on fluorescein staining)
6.Note PERRLA
7.Determine presence of red fundus reflex.
8.Examine fundus and optic disk; pupils may be dilated with 2.5% phenylephrine hydrochloride unless you suspect glaucoma (do you know why?)

Front 6

When should a patient be refered to an ophthalmologist?

Back 6

1.Limbal flush
2.Irregular pupil
3.Muscle paresis
4.Hazy cornea
5.Corneal dendrite
6.Corneal ulcer
7.Vision loss
8.Elevation of retina on funduscopic examination
9.Papilledema
10.Painful eye, red eye, and vision change

Front 7

How to treat a blunt trauma or eye penetration for stabilization

Back 7

Make a soft donut out of gauze and put rasied eye shield or cup restign on donut on affected eye then keep in place with head wrap with gauze to keep in place. Cover unaffected eye to help prevent eye movement which could further damage injured eye

Front 8

How is intraocular pressure determined?

Back 8

the balance of prduction and reabsorptioni of aqueous humor. Normal 10-21mm/HG

Front 9

What is acute angle glaucoma?

Back 9

It is when the pressure in the eye increases which stops the reabsorption of aqueous humor. The iris touches the trabecular meshwork of pupil and obstructs flow. Will see pupillary dilation. Can cause ischemia adn optic nerve damage d/t high intraocular pressure. Accounts for 5% of all glaucoma - eye emergency

Front 10

What is clinical presentation of acute angel glaucoma?

Back 10

unilateral painful eye and sudden decreased or blurred vision, N/V, see halos around lights, decreased visual acuity, pupil minimally or unresponsive to light, cornea hazy and edematous, clinical diagnosis is IOP > 50

Front 11

What is the oblique flashlight test in relation to acute angle glaucoma?

Back 11

Hold penlight on temporal side of eye, illuminate lateral aspect of eye. normally light will illuminate nasla side of iris, with narrow angle or glaucoma light will cast a shadow on nasal side. If glaucoma suspected pt needs to be refered.

Front 12

What determines the damage to eye with chemical exposure?

Back 12

volume exposed to eye, concentration PH & time to irrigation

Front 13

What kind of injury can an acid cause to eye?

Back 13

usually limited to cornea

Front 14

What kind of injury can an alkali burn cause to eye?

Back 14

usually more serious than acid burn - potential for deep injury in short time

Front 15

How long should irrigation continue with a chemical burn to eye?

Back 15

5-15 mintues - minimum 1 liter for acids adn 2 liters fo alkalis anethetize eye first. must transport to hospital. can test pH with urine dipstick - normal pH of tears is 7.4 - recheck 10-20 min as pH may have tested irrigation solution

Front 16

How to diagnose foreign body in eye?

Back 16

can use anesthetic if necessary. do eyelid eversion to check under eyelid then inspect cornea with magnification & with cobalt blue light source (woods light), use fluorescein stain if no object is seen or if once removed

Front 17

How to do exam with fluorescein stain?

Back 17

fluorescein fluoresces in alkaline environment which is found below corneal epithelium, but not in lacrimal fluid so if cornea has been breached the stain will show up when looked at iwth cobalt blue light (woods light). fluorescein stain comes in strips - moisent with NS and touch to base of globe - abrasions show up as bright yellow or yellow-green

Front 18

What is treatment for corneal foreign bodies?

Back 18

can be removed with moist sterile cotton tipped appicator or irrigation

Front 19

Why are iron or metallic objects risks for ruptured globe or problems?

Back 19

Need to make sure get metal out and rust ring. metal can penetrate sclera and then sclera can close around object where it cannot be seen.

Front 20

What is a positive Siedel test?

Back 20

when blue or green fluid is seen streaming from a point on globe after fluorescein stain has used and visualize with cobalt blue light. Usually indicated globe penetration. Usually needs large amount of stain to show test and is not really very sensitive for perforated globe - positive result send to ER via ambulance

Front 21

How to treat a corneal abrasion?

Back 21

with loss of corneal epithelial barrier can be predisposed to infection - treat with antibiotics & systemic NSAIDS or narcotics do not use topical anesthetics as they delay healing & cause secondary keratitis (corneal inflamation), eye patching not reccommended - repeat exam 24-48 perfereably by opthalmologist

Front 22

What is clinical presentation of corneal abrasion?

Back 22

foreign body sensation, pain, tearing, and sometimes photophobia, injection and blepharospasm

Front 23

What is clinical presentation of ruptured globe?

Back 23

suspect wtih blunt trauma when presenting with pain and visual impairment, large conjuctival hemorrphage, hyphema (bld in front of eye), limited extraocular eye movements - characteristic finding is irregular or tear shaped pupil

Front 24

What is treatment for ruptured globe or penetrating eye injury?

Back 24

protect eye, apply Fox shield of tapered up to eye, make sure no pressure is on eye. Start IV and give anti-emetic, arrage for emergent transport to hospital

Front 25

What are dangers of corneal abrasion?

Back 25

loss of vision, corneal ulcer, loss of eye

Front 26

What are greatest causes of corneal abrasions?

Back 26

Adults - foreign object work or home. Children - BB gun, projective metallic objects, falls, sports injuries

Front 27

What about eye patch with corneal abrasions?

Back 27

prolonged use over 48 hours can result in amblyopia (lazy eye in chldren) do not use in children under 5, use in adults for 24-48 until next office visit

Front 28

Is tetunus booster needed for corneal abrasion?

Back 28

Yes if not have one in 5 years

Front 29

Who is at risk for corneal abrasion?

Back 29

contact lens wearers, hx exposure to UV light - increased sunlight, tanning beds

Front 30

When to refer corneal abrasion?

Back 30

onset of corneal opacities, presence of rust ring, increased pain, loss of vision, nonresolution of abrasion

Front 31

Name some alkali compounds ?

Back 31

lye, lime, mortar, cement, plaster and liquid ammonia - if any of these get in eye it is an ocular emergency. Get to ER

Front 32

When shoudl eye irrigation not be used?

Back 32

make sure no globe penetration before doing eye irrigation

Front 33

What are some ophthalmic antibiotics?

Back 33

eryc, gentamycin, tobramycin, sulfacetamide

Front 34

What is an important first test with eye injury?

Back 34

test & document visual acuity - can use Snellen eye chart. Document each eye seperately - proves visual changes d/t injury and not eye exam & give baseline vision acuity

Front 35

What is a cataract?

Back 35

opacity of lens - decreasing visual acuity

Front 36

How to treat a hordeolum (stye)

Back 36

warm compresses, will hasten stye to point and drainage, antibiotic drops for 1 week, pull eyelash if associated with certain eye lash, lid scrubs can be used for recurrent lesions

Front 37

What can cause conjuctivitis?

Back 37

allergies, viral (can get from public swimming pools) or bacterial

Front 38

What to assess with conjuctivitis?

Back 38

PERRLA, eyelids, invert eye lids (cobblestone appearance indictes allergic response), sclera and cornea, periauricular andf submandibular glands - history very important, use fluorescein staining to asses corneal abrasions

Front 39

What is orbital or periorbital cellulitis?

Back 39

results from trauma or insect bite of periorbital tissues, erythema, warmth, tenderness, swelling, usually unilateral, fever

Front 40

WHat is a pterygium?

Back 40

deneratative lesion of conjuctivia r/t from chronic exposure to sun, wind or environmental irritants

Front 41

HOw long will a subconjutival hemorrhage take to absorb?

Back 41

1-2 weeks, benign, no treatment

Front 42

Which is a more serious nose bleed - anterior or posterior?

Back 42

Anterior usually seen in people under 40 and most common. Posterior seen in persons older than 40 adn more serious bleed

Front 43

What is most common cause of epistatis?

Back 43

upper resp infection and trauma some have no causes - ask about medications, cocaine use, ASA use, hx liver or renal failure, immunosuppresant meds or elevated B/P

Front 44

Management of anterior epistaxis

Back 44

direct pressure to lower nose - kisselbach's area. First have patient evacuate nose of blood or clots and then apply direct pressure for 10 minutes have pt not stop pressure, sitting straight up leaning forward, apply local anesthetic and vasoconstrictor, Assess area with nasal speculum and light, look at Kiesselbach's plexus, and use silver nitrate 10-15 seconds continuously rotating if can find previous bleeding source- not effctive with ongoing bleeding if needed, if bleeding use cautery, if cannot find bleedign site can rub mucosa with swab to induce bleeding so cn cauterize to prevent future rebleed from same site, if bleeding not stopped by these measures insert nasal tampon (can coat iwth antibiotic ointment) or pack with vaseline gauze - if still not stopped suspect posterior epistaxis, ambulance transport

Front 45

Management of posterior epistaxis

Back 45

Nasal tampon, nasostat (double balloon catheter that compressies anterior and posterior balloon or foley catheter used in posterior nares and insert tampon anteriorly

Front 46

How long to observe pt after epistaxis

Back 46

30 minutes for reocurance bleeding. instruct to use vaseine or bacitracin ointment 3x/day

Front 47

How long to leave packing in place

Back 47

Anterior At least 24-48 hours and f/u with ENT, put on antibiotic as inc risk for sinus infection. If posterior packing or balloon inserted immediate hospitalization required

Front 48

when to refer to epistaxis?

Back 48

Any pt > 40 with nasal hemmorrhage wit post history of CAD, pulmonary, hepatice or renal disorders use anterior packing & refer to ER - send all posterior packing to hospital

Front 49

What size of foley cath to use for posterior epistaxis?

Back 49

14 F

Front 50

What is peritonsillar abcess?

Back 50

complication of tonsilitis, infection spreads from tonsils to peritonsilar tissue. usually seen in pt over 10, can cause airway obstruction, abcess in neck, carotid hemmorrahge

Front 51

What is the clinical presentation of peritonsillar abscess?

Back 51

fever, sore throat x several days, then becomes unilateral & increasingly painful. Inability of pt to open mouth, palate bulges, need to send to ENT for drainage and consideration for hospital admission and IV antibiotics

Front 52

When to refer a throat problem?

Back 52

peritonsillar abscess and epiglottis - mechanical obstruction to the flow of air, which creates the emergency situation - hear stridor

Front 53

What is hte major cause of sore throat?

Back 53

strep, not common before 3yo and >50, fever >101, pain, diff swallowing pharyngeal erythema, exudate

Front 54

How to differentiate between croup and epiglottis

Back 54

The triad of drooling, agitation and the absence of a cough have been found to be very useful in differentiating epiglottitis from croup. The mean age for epiglottitis has risen from 3 years to 7 years of age, but keep in mind it can happen to anyone at any age. Adolescents and adults may simply complain of a sore throat without stridor.

Front 55

What is cause of epiglottis?

Back 55

usually bacterial - acute inflammation of the epiglottis & surrounding tissues. Not as coomon in children d/t Hamephalis B vaccine

Front 56

S/S of epiglottis

Back 56

severe sore throat, dysphagia, fever SOA, neck tenderness, cough, drooling, stridor, resp distress, & hoarseness. Pt adopt tripod position & use accessory muscles to breath - if suspect epiglottis - do not use tongue depressor as may precipitate airway emergency - need hospitatlization in ICU

Front 57

What see in bacteial pharygitis r/t viral?

Back 57

Bacterial rhinits, cough, conjuctivitis and myaliga not typically present. With Viral pharyngitis painful or tender lympn nodes not typically present. Viral with mild erythema with littel or no exudate pharynx pale, swollen or boggt

Front 58

What is critera for treating tonsilitis?

Back 58

do not treat viral. Bacterial see exudate, red throat, swollen lymph nodes, absence of cough.