Assessment: Eyes and Ears

1
Assessment Eyes and Ears

• Health Assessment
• Nu 325
• Su 2010

2
Examination of the Eyes

• Preparation
• Client sitting up with head at your eye level
• Equipment
• Snellen eye chart
• Jaeger card
• Opaque card or occluder
• Penlight

3
Subjective Data

• Vision difficulty
• ? Acuity
• Night blindness
• Blurring
• Blind spots
• Floaters
• Halos or rainbows around objects

4
Subjective Data

• Pain
• Strabismus, diplopia
• Redness, swelling
• Watering, discharge
• Past hx ocular problems
• Surgery, allergies
• Glaucoma
• Testing, family hx

5
Subjective Data

• Use of glasses or contact lenses
• Effectiveness
• Last prescription
• Problems
• Contact care
• Self-care behaviors
• Last eye exam
• Home work environment

6
Subjective Data

• Current medications
• Systemic or topical
• Eye medications

7
Subjective Data Infants Children

• Maternal vaginal infections at delivery
• Developmental milestones of vision
• Routine vision testing at school?
• Safety measures from eye trauma

8
Subjective Data Elderly

• Visual difficulty
• Stair climbing
• Driving
• Night vision
• Last glaucoma test
• Hx cataracts, visual loss, progressive blurring
• Drying or burning of eyes
• Trouble reading or sewing

9
Objective DataTest Central Visual Acuity

• Snellen eye chart Distance vision
• 20 feet
• Use an opaque card
• Leave on glasses or contacts
• Remove reading glasses
• Ask to read smallest line of print possible
• Encourage to read next line also
• Normal 20/20 both eyes
• Numerator distance from chart
• Denominator distance normal eye could have read
  chart

10
Snellen Eye Chart
11
Objective DataTest Central Visual Acuity

• Snellen Eye Chart Distance vision
• If unable to see largest letters, shorten
  distance, e.g., 10/200
• If acuity is lt, ask to count your fingers or
  distinguish light perception with penlight
• Jaeger Card Near vision (gt 40 y/o or problems
  reading)
• 14 inches
• Test eyes separately with glasses on
• Normal Jaeger 14/14 in each eye
• If no card, use newsprint or magazine

12
Jaeger Card
13
Visual Pathways Visual Fields
14
Objective Data Test Visual Fields

• Confrontation Test
• Gross measure of peripheral vision
• Compares clients with yours
• Eye level, 2 feet from client
• Client covers one eye with card stares straight
• You cover your opposite eye
• Penlight or flicking finger advancing from
  periphery, slightly behind client
• Client says, Now when target seen
• Normal 500 upward, 900 temporal, 700 down, 600
  nasal
• Document Visual fields intact WNL by
  confrontation

15
Confrontation Test
16
Range of Peripheral Fields
17
Objective Data Test Extraocular Muscle Function

• Corneal Light Reflex
• Assess parallel alignment of eyes
• Shine light directly into eyes
• Client stares straight ahead
• Note reflection of light on corneas
• Normal Symmetric
• If asymmetry, perform cover test
• Document Corneal light reflex symmetric
  bilaterally

18
Objective Data Test Extraocular Muscle Function

• Cover Test
• Tests small degrees of deviated alignment
• Client stares straight ahead
• Cover one eye with opaque card
• Note uncovered eye
• Normal Fixed steady gaze
• Uncover eye
• Observe previously covered eye
• Normal Stays straight
• Repeat with other eye

19
Cover Test
20
Objective Data Test Extraocular Muscle Function

• 6 Cardinal Positions of Gaze
• AKA Diagnostic Positions Test
• Client holds head steady follows finger or
  penlight with eyes only
• Hold target 12 inches back
• Move to 6 positions
• Hold momentarily, then back to center, progress
  clockwise
• Can also use H
• Normal Parallel tracking with both eyes

21
Objective Data Test Extraocular Muscle Function

• 6 Cardinal Positions of Gaze
• Note any nystagmus
• Mild Normal at extreme lateral gaze
• Abnormal any other position denotes weakness of
  EOM or dysfunction of the CN innervating it
• Note upper lid overlaps superior iris
• Even with downward movement
• Lid lag occurs with hyperthyroidism

22
Extraocular Muscles
23
Extraocular Muscles Direction of Movement
24
Six Cardinal Positions of Gaze
25
Objective DataInspect External Ocular Structures

• General
• Gross visual ability
• Facial expression
• Eyebrows
• Present bilaterally move symmetrically
• No scaling or lesions
• Eyelids lashes
• Upper lids overlap superior iris
• Approximate completely when closed
• Intact no redness, discharge, swelling or
  lesions
• Palpebral fissures horizontal
• Asians upward slant
• Lashes evenly distributed curve outward

26
Anatomy of the External Eye
27
Objective DataInspect External Ocular Structures

• Eyeballs
• Aligned, not protruding or sunken
• Blacks Slight protrusion normal
• Conjunctiva sclera
• Client looks up
• Slide lower lids down with thumbs
• Do not push eyeball
• Eyeball should be moist, glossy, small blood
  vessels visible but otherwise conjunctivae clear
• Palpebral conjunctiva pink
• Sclera china white
• Dark-skin Gray-blue or muddy, freckles, yellow
  fat deposits under lids
• Abnormal Jaundice scleral icterus

28
Examination of Conjunctiva Sclera
29
Objective DataInspect External Ocular Structures

• Lacrimal apparatus
• Client looks down
• Use thumbs to slide outer upper lid along bony
  orbit
• Inspect for redness, swelling, tenderness
• Check puncta lacrimal gland
• Press index finger against sac just inside lower
  orbital rim (not nose)
• Assess for tenderness, redness, discharge

30
Lacrimal Apparatus
31
Inspection of Nasolacrimal Duct
32
Objective Data Inspect Anterior Eyeball
Structures

• Cornea Lens
• Shine light from side
• Check smoothness, clarity
• Arcus senilus normal in elderly (see p.325)
• Iris Pupil
• Iris flat, round, even color
• Note pupil size, shape, equality
• 5 people have anisocoria

33
Anterior Eye Structures
34
Internal Anatomy of the Eye
35
Objective Data Inspect Anterior Eyeball
Structures

• Pupillary Light Reflex
• Darken room, client gazes into distance
• Advance light from side
• Note direct consensual response
• Can gauge in mm (Normal 3-5mm)
• R 3/1 3/1 L
• Test Accommodation Convergence
• Client focuses on distant object
• Shift gaze to object 3 inches from eyes
• Normal Pupils constrict converge
• Document PERRLA

36
Pupillary Light Reflex
37
Testing Accommodation Convergence
38
Actual Nursing Diagnosis

• Disturbed visual perception related to improper
  use of contact lenses as evidenced by excessive
  tearing and inflammation

39
Examination of the Ears

• Preparation
• Client sitting straight up, head at eye level
• If ear canal obstructed with cerumen, may need to
  irrigate (eardrum intact)
• Soften w/ warm mineral oil H2O2
• Irrigate with warm water bulb syringe
• Equipment
• Otoscope with bright light
• Tuning fork

40
Subjective Data

• Earaches
• Describe sx
• Accompanying cold sx or sore throat
• Hx trauma
• Infections
• Adult, child, treatment
• Discharge
• Appearance, odor, relation to pain
• Hearing loss
• Actual
• Family hx

41
Subjective Data

• Environmental noise
• Tinnitus
• Vertigo
• Self-care behaviors
• Infants children
• Ear infections
• Hearing
• Trauma, injury

42
Objective DataInspect Palpate External Ear

• Size shape
• Skin condition
• Tenderness
• External auditory meatus

43
External Ear Structures
44
Objective DataInspect Using the Otoscope

• Use largest speculum that fits comfortably
• Tilt head toward opposite shoulder
• Pull pinna up back for adult or older child
• Pull pinna down if infant to lt 3 yrs
• Pull gently but firmly until done with otoscopic
  exam

45
Infant vs. Adult Eustachian Tube
46
Positioning Pinna
47
Objective DataInspect Using the Otoscope

• Hold otoscope upside down
• Dorsa of your hand against cheek
• Insert speculum gently along axis of canal
• Avoid touchy bony section of canal wall
• If see only wall, reposition
• Rotate otoscope gently to visualize tympanic
  membrane

48
Objective DataInspect Using the Otoscope

• External Canal
• Note redness, lesions, or discharge (color
  odor)
• Tympanic membrane
• Shiny, translucent, pearly gray
• Cone-shaped light reflex
• 5 oclock right drum 7 oclock left drum
• Visualize umbo, manubrium short process
• Note position
• Flat, bulging, retracted?
• Check integrity of membrane

49
Internal Anatomy of the Ear
50
Use of Otoscope
51
Tympanic Membrane
52
Normal Right Tympanic Membrane
53
Objective DataTest Hearing Acuity

• Voice (Whisper) Test
• Test one ear at a time
• Place one finger on the tragus rapidly push it
  in out of the auditory meatus
• Shield lips position 1-2 ft away from ear
• Whisper 2 syllable words, e.g., Tuesday, baseball

54
Objective DataTest Hearing Acuity

• Tuning Fork Tests
• Activate fork by holding stem striking gently
  on back of hand
• Weber test
• Place tuning fork on midline of skull
• Normal Tone heard midline without lateralization
• Rinne test
• Place stem of vibrating tuning fork on mastoid
  process
• Signal when sound stops
• Move vibrating end near ear canal
• AC gt BC (ratio 21)

55
Weber Test
56
Rinne Test
57
Pathways of Hearing
58
Actual Nursing Diagnosis

• Disturbed sensory process related to excessive
  ear wax as evidenced by abnormal hearing test

59
Homework

• Do practice tests for chapters covered
• Read text lab manual review online video clips
• Head Neck, Chapter 13
• Nose, Mouth Throat, Chapter 16
• Please bring 2 pencil to class

60
Skills Lab

• Complete lab manual pp. 124-126 133-136
• Perform eye and ear exam on partner